Healthcare Provider Details

I. General information

NPI: 1073875688
Provider Name (Legal Business Name): ILEANA VICINAIZ RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2012
Last Update Date: 06/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 COUNTRY LN
PALMHURST TX
78573-8353
US

IV. Provider business mailing address

2305 COUNTRY LN
PALMHURST TX
78573-8353
US

V. Phone/Fax

Practice location:
  • Phone: 956-519-7509
  • Fax:
Mailing address:
  • Phone: 956-519-7509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT02610
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: