Basic Information
| Provider Information | |||||||||
| NPI: | 1053325787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUINONEZ | ||||||||
| FirstName: | ARACELIS | ||||||||
| MiddleName: | LOPEZ | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5 CALLE JOSE P H HERNANDEZ | ||||||||
| Address2: | |||||||||
| City: | RIO GRANDE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007452931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875507783 | ||||||||
| FaxNumber: | 7877344129 | ||||||||
| Practice Location | |||||||||
| Address1: | 1454 MADISON AVE W | ||||||||
| Address2: | |||||||||
| City: | IMMOKALEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341422200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583000 | ||||||||
| FaxNumber: | 2396583199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 01/30/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | ND7870 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 1293 | PR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | JF512Z | 01 | FL | MEDICARE ID | OTHER |