Healthcare Provider Details

I. General information

NPI: 1437766946
Provider Name (Legal Business Name): HERNAN ENSALDO DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 W MAIN ST
INDEPENDENCE KS
67301-8446
US

IV. Provider business mailing address

PO BOX 688
INDEPENDENCE KS
67301-0688
US

V. Phone/Fax

Practice location:
  • Phone: 620-331-1748
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11801
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: