MEDICARE: ILIA DE LOS ANGELES DIAZ MOURE RBT

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	247200000X	Other Technician	RBT-20-129234	FL

General Provider Information

NPI Number	:	1700496106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILIA DE LOS ANGELES DIAZ MOURE RBT

Provider Business Mailing Address
First Line	:	4705 NW 7TH ST APT 305-7
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-2259
Country	:	US
Telephone Number	:	786-663-6125
Fax Number	:

Provider Business Practice Location Address
First Line	:	4705 NW 7TH ST APT 305-7
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-2259
Country	:	US
Telephone Number	:	786-663-6125
Fax Number	:

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

Provider Enumeration Date	:	07/31/2020
Last Update Date	:	07/31/2020

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