Healthcare Provider Details

I. General information

NPI: 1649708793
Provider Name (Legal Business Name): DOUGLAS BRIAM DIAZ RADT II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40700 CALIFORNIA OAKS RD
MURRIETA CA
92562-5795
US

IV. Provider business mailing address

2088 E LAKESHORE DR APT 715
LAKE ELSINORE CA
92530-4490
US

V. Phone/Fax

Practice location:
  • Phone: 951-894-5072
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRII5751116
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: