Healthcare Provider Details

I. General information

NPI: 1790832103
Provider Name (Legal Business Name): MARILIS DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 NW 29TH ST
MIAMI FL
33127-3929
US

IV. Provider business mailing address

1271 SW 124TH CT APT C
MIAMI FL
33184-2352
US

V. Phone/Fax

Practice location:
  • Phone: 305-571-5121
  • Fax:
Mailing address:
  • Phone: 305-551-8806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number140103545342669
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: