Provider Demographics
NPI:1073972956
Name:BAEZ-RIVERA, MIREYA
Entity Type:Individual
Prefix:
First Name:MIREYA
Middle Name:
Last Name:BAEZ-RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CARR 129 KM 0.1 AVE SAN LUIS
Mailing Address - Street 2:DR. SUSONI HEALTH COMMUNITY SERVICE, CORP.
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612
Mailing Address - Country:US
Mailing Address - Phone:787-650-7272
Mailing Address - Fax:787-650-7248
Practice Address - Street 1:CARR 129 KM 0.1 AVE SAN LUIS
Practice Address - Street 2:DR. SUSONI HEALTH COMMUNITY SERVICE, CORP.
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:787-650-7272
Practice Address - Fax:787-650-7248
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1297133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1297OtherPROFESSIONAL LICENSE