Healthcare Provider Details

I. General information

NPI: 1710031661
Provider Name (Legal Business Name): IDALIA BURGOS LND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 CALLE GEN DEL VALLE URB LAS DELICIAS
SAN JUAN PR
00924-3722
US

IV. Provider business mailing address

B40 CALLE 2 URB.PASEO LAS VISTAS
SAN JUAN PR
00926-5951
US

V. Phone/Fax

Practice location:
  • Phone: 787-376-4116
  • Fax:
Mailing address:
  • Phone: 787-376-4116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number114
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: