Provider Demographics
NPI:1265848139
Name:NUTRITIONAL IMPACT BY LYZMAR CORDERO PSC
Entity Type:Organization
Organization Name:NUTRITIONAL IMPACT BY LYZMAR CORDERO PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NUTRITIONIST AND DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYZMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:LND
Authorized Official - Phone:787-410-3947
Mailing Address - Street 1:201 CALLE TETUAN # 8
Mailing Address - Street 2:OLD SAN JUAN
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00901-1816
Mailing Address - Country:US
Mailing Address - Phone:787-410-3947
Mailing Address - Fax:
Practice Address - Street 1:201 CALLE TETUAN # 8
Practice Address - Street 2:OLD SAN JUAN
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00901-1816
Practice Address - Country:US
Practice Address - Phone:787-410-3947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1634261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service