Healthcare Provider Details

I. General information

NPI: 1366560047
Provider Name (Legal Business Name): MR. JOHN ANTHONY DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 01/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 ELM AVE
LONG BEACH CA
90802-2426
US

IV. Provider business mailing address

456 ELM AVE
LONG BEACH CA
90802-2426
US

V. Phone/Fax

Practice location:
  • Phone: 562-437-6717
  • Fax: 562-437-5072
Mailing address:
  • Phone: 562-437-6717
  • Fax: 562-437-5072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number698617
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number698617
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: