MEDICARE: MR. BRIAN DAVID DIAZ M.P.T.

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	225100000X	Physical Therapist	P8453	NC

General Provider Information

NPI Number	:	1609964717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN DAVID DIAZ M.P.T.

Provider Business Mailing Address
First Line	:	4221 GARRETT RD STE 2
Second Line	:	ACTIVEDGE FITNESS & SPORTS PERFORMANCE
City	:	DURHAM
State	:	NC
Zip	:	27707-3467
Country	:	US
Telephone Number	:	919-493-1204
Fax Number	:	919-493-1204

Provider Business Practice Location Address
First Line	:	4221 GARRETT RD STE 2
Second Line	:	ACTIVEDGE FITNESS & SPORTS PERFORMANCE
City	:	DURHAM
State	:	NC
Zip	:	27707-3467
Country	:	US
Telephone Number	:	919-493-1204
Fax Number	:	919-493-1204

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2007

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