Healthcare Provider Details

I. General information

NPI: 1871140152
Provider Name (Legal Business Name): KAREN TREVIZO-DIAZ CAMTC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9197 CENTRAL AVE STE H
MONTCLAIR CA
91763-1616
US

IV. Provider business mailing address

1030 N MOUNTAIN AVE # 155
ONTARIO CA
91762-2114
US

V. Phone/Fax

Practice location:
  • Phone: 909-276-7554
  • Fax:
Mailing address:
  • Phone: 909-276-7554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number32886
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: