=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285428961
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NOAH JAKE DIAZ DE LA CUESTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2025
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2010 RECREATION LN
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44011-1169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-934-9622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2010 RECREATION LN
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44011-1169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-934-9622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------