Provider Demographics
NPI:1023551942
Name:PRINCE-PEREZ, SAMANTHA RIQUEL (RD, LD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RIQUEL
Last Name:PRINCE-PEREZ
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6821
Mailing Address - Country:US
Mailing Address - Phone:877-800-5722
Mailing Address - Fax:
Practice Address - Street 1:7000 WOODHUE DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5454
Practice Address - Country:US
Practice Address - Phone:512-439-8924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-25
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84116133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered