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General NPI Number Information
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NPI Number | 1265848139
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Entity Type | Organization
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Legal Business Name | NUTRITIONAL IMPACT BY LYZMAR CORDERO PSC
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Dates
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Enumeration Date | 07/10/2014
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Last Update Date | 07/10/2014
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Provider Practice Location Address
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Address Line | 201 CALLE TETUAN # 8 OLD SAN JUAN
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City | SAN JUAN
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State | PR
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Zip | 00901-1816
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Country | US
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Telephone | 787-410-3947
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Fax |
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Provider Business Mailing Address
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Address Line | 201 CALLE TETUAN # 8 OLD SAN JUAN
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City | SAN JUAN
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State | PR
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Zip | 00901-1816
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Country | US
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Telephone | 787-410-3947
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Fax |
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Authorized Official
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Title or Position | NUTRITIONIST AND DIETITIAN
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Name | MRS. LYZMAR CORDERO
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Credential | LND
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Telephone | 787-410-3947
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 1634
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License Number State | PR
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