Healthcare Provider Details

I. General information

NPI: 1922921519
Provider Name (Legal Business Name): JORGE MANUEL DIAZ NIETO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 E 39TH PL
HIALEAH FL
33013-2865
US

IV. Provider business mailing address

870 E 39TH PL
HIALEAH FL
33013-2865
US

V. Phone/Fax

Practice location:
  • Phone: 305-775-9528
  • Fax:
Mailing address:
  • Phone: 305-775-9528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberD625-953-84-100-0
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: