Healthcare Provider Details

I. General information

NPI: 1982995403
Provider Name (Legal Business Name): ALEJANDRO DIAZ JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 W HENRY ST
PASCO WA
99301-4117
US

IV. Provider business mailing address

PO BOX 4695 719 W. HENRY ST.
PASCO WA
99302-4695
US

V. Phone/Fax

Practice location:
  • Phone: 509-308-4825
  • Fax:
Mailing address:
  • Phone: 509-308-4825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberMC10659
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: