Basic Information
| Provider Information | |||||||||
| NPI: | 1750564498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARBONELL | ||||||||
| FirstName: | ALBA | ||||||||
| MiddleName: | IRIS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LND | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARBONELL | ||||||||
| OtherFirstName: | ALBA | ||||||||
| OtherMiddleName: | IRIS | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LND | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 110 CALLE PEDRO ARZUAGA E | ||||||||
| Address2: | VILLAS DEL CENTRO APT. # 52 | ||||||||
| City: | CAROLINA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009856167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875505362 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1715 AVE PONCE DE LEON | ||||||||
| Address2: | NUTRITION DEPARTMENT | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009091958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582000 | ||||||||
| FaxNumber: | 7877717951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2007 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
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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 | 133NN1002X | 1235 | PR | Y | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
ID Information
| ID | Type | State | Issuer | Description | 1235 | 01 | PR | LND | OTHER | 1235 | 01 | PR | CLE | OTHER |