Healthcare Provider Details

I. General information

NPI: 1073005187
Provider Name (Legal Business Name): LUIS SANTIAGO GARCIA DIAZ SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 E CHAUNCEY LN APT 1028
PHOENIX AZ
85054-5104
US

IV. Provider business mailing address

PO BOX 2550
ROWLETT TX
75030-2550
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number16-166
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: