MEDICARE: CANDIDA COLON LND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	805	PR

General Provider Information

NPI Number	:	1548237712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDIDA COLON LND

Provider Business Mailing Address
First Line	:	COND BONNEVILLE
Second Line	:	7 GUAYNABO
City	:	CAGUAS
State	:	PR
Zip	:	00725-5606
Country	:	US
Telephone Number	:	787-744-2516
Fax Number	:

Provider Business Practice Location Address
First Line	:	URB BAIROA
Second Line	:	BS4 LAS AMERICAS AVE
City	:	CAGUAS
State	:	PR
Zip	:	00725-0000
Country	:	US
Telephone Number	:	787-746-7066
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	10/15/2010

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