Healthcare Provider Details

I. General information

NPI: 1174415137
Provider Name (Legal Business Name): KOETTA DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7502 GRACE AVE
CLEVELAND OH
44102-4240
US

IV. Provider business mailing address

2150 W 117TH ST
CLEVELAND OH
44111-1641
US

V. Phone/Fax

Practice location:
  • Phone: 517-240-2519
  • Fax:
Mailing address:
  • Phone: 216-760-9768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: