MEDICARE: MIRABELLA MACIAS

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	1324	NM

General Provider Information

NPI Number	:	1598353906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRABELLA MACIAS

Provider Business Mailing Address
First Line	:	2700 BOLDT ST
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-3876
Country	:	US
Telephone Number	:	575-640-2758
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 BOLDT ST
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-3876
Country	:	US
Telephone Number	:	575-640-2758
Fax Number	:

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

Provider Enumeration Date	:	01/02/2021
Last Update Date	:	01/02/2021

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Directions to “ MIRABELLA MACIAS ” Practice Location

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