Provider Demographics
NPI:1376020610
Name:VEGA-SEPULVEDA, WILLIAM MIGUEL SR (LND)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MIGUEL
Last Name:VEGA-SEPULVEDA
Suffix:SR
Gender:M
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:BARRIADA ROOSEVELT
Mailing Address - Street 2:172 CALLE SAN ISIDRO
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738
Mailing Address - Country:US
Mailing Address - Phone:414-204-9486
Mailing Address - Fax:
Practice Address - Street 1:BARRIADA ROOSEVELT
Practice Address - Street 2:172 CALLE SAN ISIDRO
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:414-204-9486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2071133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education