MEDICARE: MRS. GABRIELA E LOPEZ 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	133N00000X	Nutritionist	1327	PR

General Provider Information

NPI Number	:	1669625943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GABRIELA E LOPEZ LND

Provider Business Mailing Address
First Line	:	652 CALLE ROOSEVELT
Second Line	:	APT 3
City	:	SAN JUAN
State	:	PR
Zip	:	00907-3409
Country	:	US
Telephone Number	:	787-777-3535
Fax Number	:	787-777-3262

Provider Business Practice Location Address
First Line	:	652 CALLE ROOSEVELT
Second Line	:	APT 3
City	:	SAN JUAN
State	:	PR
Zip	:	00907-3409
Country	:	US
Telephone Number	:	787-777-3535
Fax Number	:	787-777-3262

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

Provider Enumeration Date	:	10/30/2008
Last Update Date	:	10/30/2008

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