Provider Demographics
NPI:1679650592
Name:BECERRA-SOBERON, ROSA LOURDES (RD, LD/N)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:LOURDES
Last Name:BECERRA-SOBERON
Suffix:
Gender:F
Credentials:RD, LD/N
Other - Prefix:
Other - First Name:ROSA
Other - Middle Name:LOURDES
Other - Last Name:BECERRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1244 SW 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-1644
Mailing Address - Country:US
Mailing Address - Phone:305-878-0656
Mailing Address - Fax:
Practice Address - Street 1:1815 COUNTRY LN
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-6451
Practice Address - Country:US
Practice Address - Phone:305-878-0656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2716133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered