Healthcare Provider Details

I. General information

NPI: 1487311486
Provider Name (Legal Business Name): JESUS DIAZ GARCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12555 LAKEWOOD BLVD STE F
DOWNEY CA
90242-2771
US

IV. Provider business mailing address

45046 PROMISE RD
LAKE ELSINORE CA
92532-1500
US

V. Phone/Fax

Practice location:
  • Phone: 562-923-4704
  • Fax:
Mailing address:
  • Phone: 909-272-3221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number51544
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: