Basic Information
| Provider Information | |||||||||
| NPI: | 1396096012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | DIETITIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19-15 CALLE 21 | ||||||||
| Address2: | |||||||||
| City: | BAYAMON | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009614517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876716831 | ||||||||
| FaxNumber: | 7877717426 | ||||||||
| Practice Location | |||||||||
| Address1: | 1715 AVE PONCE DE LEON | ||||||||
| Address2: | NUTRITION DEPT. | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009091958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2012 | ||||||||
| LastUpdateDate: | 09/20/2012 | ||||||||
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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 | 133N00000X | 1556 | PR | Y | Dietary & Nutritional Service Providers | Nutritionist |
ID Information
| ID | Type | State | Issuer | Description | 1556 | 01 | PR | DIETITIAN'S LICENCE | OTHER |