Basic Information
| Provider Information | |||||||||
| NPI: | 1205248747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTIAGO | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LND | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70344 | ||||||||
| Address2: | HOSPITAL SAN JUAN RAFAEL LOPEZ NUSSA PMB #079 | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009368344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874802700 | ||||||||
| FaxNumber: | 7877643643 | ||||||||
| Practice Location | |||||||||
| Address1: | BARRIO MANACILLO CENTRO MEDICO | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009368344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874802783 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2014 | ||||||||
| LastUpdateDate: | 06/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | 1112 | PR | N | Dietary & Nutritional Service Providers | Nutritionist | 133V00000X | 1112 | PR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.