Provider Demographics
NPI:1629736780
Name:GONZALEZ GUANG, EUNICE (LCDA)
Entity Type:Individual
Prefix:
First Name:EUNICE
Middle Name:
Last Name:GONZALEZ GUANG
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11577
Mailing Address - Street 2:FERNANDEZ JUNCOS STATION
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00910
Mailing Address - Country:US
Mailing Address - Phone:787-723-5017
Mailing Address - Fax:787-723-5015
Practice Address - Street 1:1492 PONCE DE LEON AVE
Practice Address - Street 2:EDIFICIO CENTRO EUROPA 717
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907
Practice Address - Country:US
Practice Address - Phone:787-723-5017
Practice Address - Fax:787-723-5015
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001291133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR001291OtherLICENSE