Provider Demographics
NPI:1598231300
Name:PEREZ, VICTORIA SAN NICOLAS (RD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:SAN NICOLAS
Last Name:PEREZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ROUTE 8 STE 303
Mailing Address - Street 2:
Mailing Address - City:MAITE
Mailing Address - State:GU
Mailing Address - Zip Code:96910-2003
Mailing Address - Country:US
Mailing Address - Phone:671-475-0061
Mailing Address - Fax:671-475-0065
Practice Address - Street 1:400 ROUTE 8 STE 303
Practice Address - Street 2:
Practice Address - City:MAITE
Practice Address - State:GU
Practice Address - Zip Code:96910-2003
Practice Address - Country:US
Practice Address - Phone:671-475-0061
Practice Address - Fax:671-475-0065
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUD-12133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty