Healthcare Provider Details

I. General information

NPI: 1992303192
Provider Name (Legal Business Name): REUBEN ZETH DIAZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/12/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 NE LOOP 820 BUSINESS TOWER 1, SUITE 200
HURST TX
76053
US

IV. Provider business mailing address

12511 OLD GLORY AVE
SAN ANTONIO TX
78253-6334
US

V. Phone/Fax

Practice location:
  • Phone: 817-292-8787
  • Fax: 817-789-6849
Mailing address:
  • Phone: 210-954-1552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2143206
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: