Healthcare Provider Details

I. General information

NPI: 1982161758
Provider Name (Legal Business Name): DIANA MUNIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10776 FREMONT ST
YUCAIPA CA
92399-9630
US

IV. Provider business mailing address

10776 FREMONT ST
YUCAIPA CA
92399-9630
US

V. Phone/Fax

Practice location:
  • Phone: 909-797-0114
  • Fax:
Mailing address:
  • Phone: 909-797-0114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: