Healthcare Provider Details

I. General information

NPI: 1033850060
Provider Name (Legal Business Name): LUIS ALFREDO DIAZ ESTREMERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3831 W VINE ST STE 60
KISSIMMEE FL
34741-4650
US

IV. Provider business mailing address

2301 MAITLAND CENTER PKWY STE 240
MAITLAND FL
32751-7415
US

V. Phone/Fax

Practice location:
  • Phone: 407-559-4854
  • Fax: 407-965-4480
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: