Provider Demographics
NPI:1275887317
Name:GARCIA VERGARA, MORAIMA (LND)
Entity Type:Individual
Prefix:MRS
First Name:MORAIMA
Middle Name:
Last Name:GARCIA VERGARA
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CALLE LUIS MUNOZ RIVERA
Mailing Address - Street 2:
Mailing Address - City:YABUCOA
Mailing Address - State:PR
Mailing Address - Zip Code:00767-3103
Mailing Address - Country:US
Mailing Address - Phone:787-266-0907
Mailing Address - Fax:
Practice Address - Street 1:AVE. FONT MARTELO 158
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-318-2041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1666133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered