Healthcare Provider Details

I. General information

NPI: 1891933511
Provider Name (Legal Business Name): IVELISSE ALVERIO SANTANA LND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HF16 CALLE LIZZIE GRAHAM
TOA BAJA PR
00949-3634
US

IV. Provider business mailing address

PO BOX 56144
BAYAMON PR
00960-6144
US

V. Phone/Fax

Practice location:
  • Phone: 787-309-6283
  • Fax:
Mailing address:
  • Phone: 787-309-6283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number1472
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: