Provider Demographics
NPI:1427346360
Name:MERCADO MATOS, MARILIS (LND)
Entity type:Individual
Prefix:MS
First Name:MARILIS
Middle Name:
Last Name:MERCADO MATOS
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:PO BOX 1184
Mailing Address - Street 2:
Mailing Address - City:AIBONITO
Mailing Address - State:PR
Mailing Address - Zip Code:00705-1184
Mailing Address - Country:US
Mailing Address - Phone:787-318-5006
Mailing Address - Fax:
Practice Address - Street 1:CARR. 152 KM. 2.3 BO. QUEBRADILLAS
Practice Address - Street 2:
Practice Address - City:BARRANQUITAS
Practice Address - State:PR
Practice Address - Zip Code:00794
Practice Address - Country:US
Practice Address - Phone:787-857-8383
Practice Address - Fax:787-857-4848
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1521133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist