Healthcare Provider Details

I. General information

NPI: 1649579574
Provider Name (Legal Business Name): MARIA NESTLEROAD RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA BRAN ALONSO

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE ROOM 202 MAIN HOSPITAL MS333
CHARLESTON SC
29425-8905
US

IV. Provider business mailing address

169 ASHLEY AVE ROOM 202 MAIN HOSPITAL MS333
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-3886
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number864
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: