Provider Demographics
NPI:1427822428
Name:MANGUAL, GUSTAVO JOSE (LND,CDN)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:JOSE
Last Name:MANGUAL
Suffix:
Gender:M
Credentials:LND,CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 CALLE CASTANIA
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00731-9565
Mailing Address - Country:US
Mailing Address - Phone:787-638-4564
Mailing Address - Fax:
Practice Address - Street 1:196 CALLE CASTANIA
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00731-9565
Practice Address - Country:US
Practice Address - Phone:787-638-4564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2184133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist