Healthcare Provider Details

I. General information

NPI: 1952855231
Provider Name (Legal Business Name): LOURDES DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11517 SW 7TH TER
MIAMI FL
33174-1033
US

IV. Provider business mailing address

11517 SW 7TH TER
MIAMI FL
33174-1033
US

V. Phone/Fax

Practice location:
  • Phone: 305-742-7184
  • Fax:
Mailing address:
  • Phone: 305-742-7184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA25176
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: