Provider Demographics
NPI:1679963722
Name:BURGOS-VELAZQUEZ, EDWILL (LCDO)
Entity type:Individual
Prefix:
First Name:EDWILL
Middle Name:
Last Name:BURGOS-VELAZQUEZ
Suffix:
Gender:M
Credentials:LCDO
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 83
Mailing Address - Street 2:
Mailing Address - City:SANTA ISABEL
Mailing Address - State:PR
Mailing Address - Zip Code:00757
Mailing Address - Country:US
Mailing Address - Phone:787-242-6225
Mailing Address - Fax:
Practice Address - Street 1:2 CALLE SEGUNDO BERNIER
Practice Address - Street 2:
Practice Address - City:COAMO
Practice Address - State:PR
Practice Address - Zip Code:00769-3036
Practice Address - Country:US
Practice Address - Phone:787-803-8221
Practice Address - Fax:787-537-7071
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-28
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1897133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education