Provider Demographics
NPI:1720364060
Name:FUENTES, MANRIQUE JR (RD, LD)
Entity Type:Individual
Prefix:MR
First Name:MANRIQUE
Middle Name:
Last Name:FUENTES
Suffix:JR
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3406 BOB ROGERS DR STE 120
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-5942
Mailing Address - Country:US
Mailing Address - Phone:830-757-4900
Mailing Address - Fax:830-757-4982
Practice Address - Street 1:2525 N VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-3302
Practice Address - Country:US
Practice Address - Phone:830-773-6963
Practice Address - Fax:830-757-5746
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81855133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT81855OtherTX STATE BOARD OF EXAMINERS OF DIETITIANS
TX276401YQEUMedicare UPIN