Healthcare Provider Details

I. General information

NPI: 1760182877
Provider Name (Legal Business Name): OMAR DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7120 HAYVENHURST AVE STE 322
VAN NUYS CA
91406-3813
US

IV. Provider business mailing address

3200 E GUASTI RD STE 100
ONTARIO CA
91761-8661
US

V. Phone/Fax

Practice location:
  • Phone: 714-867-3813
  • Fax: 855-568-2494
Mailing address:
  • Phone: 909-304-1039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: