Provider Demographics
NPI:1093884546
Name:ACEVEDO, MAYDA I (MS,IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:MAYDA
Middle Name:I
Last Name:ACEVEDO
Suffix:
Gender:F
Credentials:MS,IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 323
Mailing Address - Street 2:
Mailing Address - City:QUEBRADILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00678-0323
Mailing Address - Country:US
Mailing Address - Phone:787-817-4962
Mailing Address - Fax:787-817-4962
Practice Address - Street 1:CARR 2 AVE. DE DIEGO 435
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:787-817-4962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR952133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR50128OtherPREFERED MEDICARE CHOICE
PR890390OtherMEDICARE Y MUCHO MAS
PR50128OtherPREFERED MEDICARE CHOICE
PRP64308Medicare UPIN