Provider Demographics
NPI:1073181491
Name:MURCIA, CARLOS HUMBERTO I
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:HUMBERTO
Last Name:MURCIA
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SLATER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-2816
Mailing Address - Country:US
Mailing Address - Phone:707-321-4809
Mailing Address - Fax:
Practice Address - Street 1:1701 SLATER ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-2816
Practice Address - Country:US
Practice Address - Phone:707-321-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-13
Last Update Date:2021-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86291705136A00000X
339359132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered