Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 007057 | GA |
NPI | 1114078474 |
---|---|
Provider Name | Jorge A Bueno |
First Address | Douglasville, GA 30135-2371 |
Second Address | Douglasville, GA 30135-2371 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/01/2007 |
Last Update Date | 20/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
113680046 | (02) | GA |