Healthcare Provider Details

I. General information

NPI: 1710531553
Provider Name (Legal Business Name): MEGAN DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date: 09/06/2019
Reactivation Date: 12/06/2019

III. Provider practice location address

400 SHADOW LN STE 106
LAS VEGAS NV
89106-4355
US

IV. Provider business mailing address

8936 SPANISH RIDGE AVE
LAS VEGAS NV
89148-1354
US

V. Phone/Fax

Practice location:
  • Phone: 702-731-0909
  • Fax: 702-826-4757
Mailing address:
  • Phone: 702-998-2816
  • Fax: 702-998-2991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: