Provider Demographics
NPI:1245431386
Name:GUSTAVO RUIZ, EDITHMAR (LND,MPH)
Entity Type:Individual
Prefix:
First Name:EDITHMAR
Middle Name:
Last Name:GUSTAVO RUIZ
Suffix:
Gender:F
Credentials:LND,MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 CALLE DON DIEGO
Mailing Address - Street 2:VILLA FLORES
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716-2921
Mailing Address - Country:US
Mailing Address - Phone:787-671-8676
Mailing Address - Fax:787-651-6339
Practice Address - Street 1:606 AVE TITO CASTRO
Practice Address - Street 2:LA RAMBLA PLAZA SUITE 135
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-0205
Practice Address - Country:US
Practice Address - Phone:787-840-6838
Practice Address - Fax:787-842-6838
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1400133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR001400OtherLICENCES