MEDICARE: UNIQUELY HEALTHY

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

General Provider Information

NPI Number	:	1730777020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIQUELY HEALTHY

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	:	REGISTERED DIETITIAN NUTRITIONIST
Name	:	MIRABELLA MACIAS
Credential	:	MS, RDN, LD
Telephone Number	:	575-640-2758

Provider Enumeration Date	:	01/04/2021
Last Update Date	:	01/04/2021

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Directions to “UNIQUELY HEALTHY ” Practice Location

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