Healthcare Provider Details

I. General information

NPI: 1578114104
Provider Name (Legal Business Name): TARYN CELESTE PRADO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15303 HUEBNER RD STE 15
SAN ANTONIO TX
78248-0983
US

IV. Provider business mailing address

15303 HUEBNER RD STE 15
SAN ANTONIO TX
78248-0983
US

V. Phone/Fax

Practice location:
  • Phone: 210-666-9905
  • Fax:
Mailing address:
  • Phone: 210-666-9905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberDT85499
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT85499
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: