Healthcare Provider Details

I. General information

NPI: 1790741742
Provider Name (Legal Business Name): CHRIS ALFONSO DIAZ ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 HARRIETT ST
MOUNT VERNON IN
47620-2031
US

IV. Provider business mailing address

670 SOUTHFIELD RD
EVANSVILLE IN
47715-6949
US

V. Phone/Fax

Practice location:
  • Phone: 812-833-5928
  • Fax: 812-833-2090
Mailing address:
  • Phone: 812-760-9431
  • Fax: 812-833-2090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000002A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: