MEDICARE: MISS MARCO ANTONIO DIAZ MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172M00000X	Mechanotherapist	MA46790	FL

General Provider Information

NPI Number	:	1588949044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARCO ANTONIO DIAZ MA

Provider Business Mailing Address
First Line	:	1865 NE 163RD ST
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33162-4805
Country	:	US
Telephone Number	:	305-948-9958
Fax Number	:	305-948-9518

Provider Business Practice Location Address
First Line	:	1865 NE 163RD ST
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33162-4805
Country	:	US
Telephone Number	:	305-948-9958
Fax Number	:	305-948-9518

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2011
Last Update Date	:	10/17/2011

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