Provider Demographics
NPI:1437926193
Name:OLIVARES, MAYRA SOFIA (MS, RDN, LD)
Entity Type:Individual
Prefix:MISS
First Name:MAYRA
Middle Name:SOFIA
Last Name:OLIVARES
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S. 10TH ST. BOX 4605
Mailing Address - Street 2:
Mailing Address - City:HIDALGO
Mailing Address - State:TX
Mailing Address - Zip Code:78557
Mailing Address - Country:US
Mailing Address - Phone:956-340-9290
Mailing Address - Fax:
Practice Address - Street 1:1001 RONE DR STE 2
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-5043
Practice Address - Country:US
Practice Address - Phone:956-600-3475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT88674133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered