Healthcare Provider Details

I. General information

NPI: 1396903290
Provider Name (Legal Business Name): MIRTA YARIS RODRIGUEZ LND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STREET VIA CUMBRES H-8 LA VISTA
SAN JUAN PR
00924
US

IV. Provider business mailing address

STREET VIA CUMBRES H-8 LA VISTA
SAN JUAN PR
00924
US

V. Phone/Fax

Practice location:
  • Phone: 787-276-1541
  • Fax:
Mailing address:
  • Phone: 787-276-1541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1281
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: