Healthcare Provider Details

I. General information

NPI: 1669188165
Provider Name (Legal Business Name): DIANA JAZMIN BETANCOURT MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2023
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TEAL RISING WAY
RIVERSIDE MO
64150-7700
US

IV. Provider business mailing address

1 TEAL RISING WAY
RIVERSIDE MO
64150-7700
US

V. Phone/Fax

Practice location:
  • Phone: 714-791-3647
  • Fax:
Mailing address:
  • Phone: 714-791-3647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-01780
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number2024030608
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: