Provider Demographics
NPI:1912208398
Name:RIVERA, GLADIBELIS (LND)
Entity Type:Individual
Prefix:MISS
First Name:GLADIBELIS
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 AVE WINSTON CHURCHILL
Mailing Address - Street 2:APT. H-301, COND. CHURCHILL PARK, BOX.77
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6627
Mailing Address - Country:US
Mailing Address - Phone:787-487-7220
Mailing Address - Fax:
Practice Address - Street 1:241 AVE WINSTON CHURCHILL
Practice Address - Street 2:APT. H-301, COND. CHURCHILL PARK, BOX.77
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-6627
Practice Address - Country:US
Practice Address - Phone:787-487-7220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1527133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1527OtherDIETITIAN LICENSE