Healthcare Provider Details

I. General information

NPI: 1013445352
Provider Name (Legal Business Name): TARA DIAZ WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 MAIN ST
EL SEGUNDO CA
90245-3006
US

IV. Provider business mailing address

519 MAIN ST
EL SEGUNDO CA
90245-3006
US

V. Phone/Fax

Practice location:
  • Phone: 424-258-0738
  • Fax:
Mailing address:
  • Phone: 424-258-0738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number15635
License Number StateCA

VIII. Authorized Official

Name: TARA SCHACHTER-DIAZ
Title or Position: OWNER
Credential: LAC
Phone: 424-258-0738