Healthcare Provider Details

I. General information

NPI: 1043939069
Provider Name (Legal Business Name): VICTORIA DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1588 W CAYUSE CREEK DR # 110
MERIDIAN ID
83646-4795
US

IV. Provider business mailing address

PO BOX 1806
DURHAM NC
27702-1806
US

V. Phone/Fax

Practice location:
  • Phone: 208-515-7575
  • Fax:
Mailing address:
  • Phone: 216-772-1030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8231
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: