Healthcare Provider Details

I. General information

NPI: 1730425976
Provider Name (Legal Business Name): RGV NUTRITION 4 LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 N 10TH ST SUITE C
MCALLEN TX
78504-3008
US

IV. Provider business mailing address

4309 N 10TH ST SUITE C
MCALLEN TX
78504-3008
US

V. Phone/Fax

Practice location:
  • Phone: 956-630-5433
  • Fax: 956-630-6389
Mailing address:
  • Phone: 956-630-5433
  • Fax: 956-630-6389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT80162
License Number StateTX

VIII. Authorized Official

Name: ILERETTE RAMIREZ
Title or Position: REGISTERED DIETITIAN/OWNER
Credential: RD/LD
Phone: 956-458-0874