Provider Demographics
NPI:1427401090
Name:MIRELES, VIDAL TREVINO JR (RDN)
Entity Type:Individual
Prefix:MR
First Name:VIDAL
Middle Name:TREVINO
Last Name:MIRELES
Suffix:JR
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6638 DANCING CT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-1708
Mailing Address - Country:US
Mailing Address - Phone:210-852-0002
Mailing Address - Fax:
Practice Address - Street 1:6638 DANCING CT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-1708
Practice Address - Country:US
Practice Address - Phone:210-852-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86046619133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered