MEDICARE: WILFRED J DIAZ PT, DPT, OCS

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	2251X0800X	Orthopedic Physical Therapist	PT32926	CA

General Provider Information

NPI Number	:	1679581763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILFRED J DIAZ PT, DPT, OCS

Provider Business Mailing Address
First Line	:	4443 LEVELSIDE AVE
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90712-3753
Country	:	US
Telephone Number	:	213-399-7052
Fax Number	:

Provider Business Practice Location Address
First Line	:	4443 LEVELSIDE AVE
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90712-3753
Country	:	US
Telephone Number	:	213-399-7052
Fax Number	:

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

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	11/20/2013

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