Healthcare Provider Details

I. General information

NPI: 1104865914
Provider Name (Legal Business Name): TERESA RODRIGUEZ BONILLA RDN. IFNCP. LDN, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA RODRIGUEZ RDN. IFNCP. LDN, CLT

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 CALLE MALLORCA
SAN JUAN PR
00917-3125
US

IV. Provider business mailing address

113 CALLE MALLORCA
SAN JUAN PR
00917-3125
US

V. Phone/Fax

Practice location:
  • Phone: 727-366-9663
  • Fax: 317-427-6078
Mailing address:
  • Phone: 727-366-9663
  • Fax: 317-427-6078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND3736
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: