MEDICARE: MRS. IDALIA BURGOS 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	114	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3264	OTHER	PR	AMERICAN HEALTH
2	NUT 005	OTHER	PR	PHP
3	9240091	OTHER	PR	HUMANA HEALTH PLAN
4	50338	OTHER	PR	PMC

General Provider Information

NPI Number	:	1710031661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IDALIA BURGOS LND

Provider Business Mailing Address
First Line	:	B40 CALLE 2
Second Line	:	URB.PASEO LAS VISTAS
City	:	SAN JUAN
State	:	PR
Zip	:	00926-5951
Country	:	US
Telephone Number	:	787-376-4116
Fax Number	:

Provider Business Practice Location Address
First Line	:	1017 CALLE GEN DEL VALLE
Second Line	:	URB LAS DELICIAS
City	:	SAN JUAN
State	:	PR
Zip	:	00924-3722
Country	:	US
Telephone Number	:	787-376-4116
Fax Number	:

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	07/08/2007

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Directions to “ MRS. IDALIA BURGOS LND” Practice Location

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