Basic Information
| Provider Information | |||||||||
| NPI: | 1073972956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAEZ-RIVERA | ||||||||
| FirstName: | MIREYA | ||||||||
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| Mailing Information | |||||||||
| Address1: | CARR 129 KM 0.1 AVE SAN LUIS | ||||||||
| Address2: | DR. SUSONI HEALTH COMMUNITY SERVICE, CORP. | ||||||||
| City: | ARECIBO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876507272 | ||||||||
| FaxNumber: | 7876507248 | ||||||||
| Practice Location | |||||||||
| Address1: | CARR 129 KM 0.1 AVE SAN LUIS | ||||||||
| Address2: | DR. SUSONI HEALTH COMMUNITY SERVICE, CORP. | ||||||||
| City: | ARECIBO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876507272 | ||||||||
| FaxNumber: | 7876507248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2016 | ||||||||
| LastUpdateDate: | 02/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1297 | PR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1297 | 01 | PR | PROFESSIONAL LICENSE | OTHER |