Provider Demographics
NPI:1770127193
Name:MAYORGA, ELIO C (MS, RD, CDN)
Entity type:Individual
Prefix:
First Name:ELIO
Middle Name:C
Last Name:MAYORGA
Suffix:
Gender:M
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 FORT LEE RD APT A
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3962
Mailing Address - Country:US
Mailing Address - Phone:347-680-9637
Mailing Address - Fax:
Practice Address - Street 1:143 FORT LEE RD APT A
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-3962
Practice Address - Country:US
Practice Address - Phone:347-680-9637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86063287133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty