Healthcare Provider Details

I. General information

NPI: 1710804802
Provider Name (Legal Business Name): ALAN JOHAN DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S GRAND AVE APT 59
ANAHEIM CA
92804-1659
US

IV. Provider business mailing address

120 S GRAND AVE APT 59
ANAHEIM CA
92804-1659
US

V. Phone/Fax

Practice location:
  • Phone: 805-628-6438
  • Fax:
Mailing address:
  • Phone: 805-628-6438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86392066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: