Healthcare Provider Details

I. General information

NPI: 1245582428
Provider Name (Legal Business Name): LEON DIAZ P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4538 N. BEACON ST
CHICAGO IL
60640
US

IV. Provider business mailing address

1126 DANVERS
SCHAMBURG IL
60194
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-7200
  • Fax:
Mailing address:
  • Phone: 847-895-1838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160006126
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: