Healthcare Provider Details

I. General information

NPI: 1396191813
Provider Name (Legal Business Name): JOSE DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

I10 CALLE 6 URB TAMARINDO 1
SAN LORENZO PR
00754
US

IV. Provider business mailing address

J-9 CALLE FLAMBOYAN URB BOSQUE LLANO
SAN LORENZO PR
00754
US

V. Phone/Fax

Practice location:
  • Phone: 787-340-5103
  • Fax:
Mailing address:
  • Phone: 787-203-9985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number71810
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number71810
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number71810
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: