MEDICARE: KIM DIAZ OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	6196	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265771836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM DIAZ OT

Provider Business Mailing Address
First Line	:	8043 MOUNT RANIER DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-2908
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8043 MOUNT RANIER DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-2908
Country	:	US
Telephone Number	:	904-642-6809
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2013
Last Update Date	:	02/02/2013

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Directions to “ KIM DIAZ OT” Practice Location

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