Basic Information
| Provider Information | |||||||||
| NPI: | 1386002335 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | MARLYNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1205 N F AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856071920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203646852 | ||||||||
| FaxNumber: | 5203644261 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 ARIZONA ST | ||||||||
| Address2: | |||||||||
| City: | BISBEE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856031804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204323309 | ||||||||
| FaxNumber: | 5204323717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2016 | ||||||||
| LastUpdateDate: | 07/26/2019 | ||||||||
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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 | 133V00000X | 2014030930 | MO | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 1036163 | AZ | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.