=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487067831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ILSIA ALICEA-POU LND
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2014
-----------------------------------------------------
Last Update Date | 06/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | AVE. HOSTOS 1034 PONCE, P.R. 00716-1415
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00716-1415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-843-9393
-----------------------------------------------------
Fax | 787-284-4228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | APARTADO 220 MERCEDITA P.R. 00715-0220
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00716-1415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-843-9393
-----------------------------------------------------
Fax | 787-284-4228
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | 1101
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------