Provider Demographics
NPI:1013223718
Name:DIAZ, ROSALIO L
Entity Type:Individual
Prefix:MR
First Name:ROSALIO
Middle Name:L
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:ROBERTS
Mailing Address - State:ID
Mailing Address - Zip Code:83444-0108
Mailing Address - Country:US
Mailing Address - Phone:208-228-2435
Mailing Address - Fax:
Practice Address - Street 1:644 NORTH 2865 EAST
Practice Address - Street 2:
Practice Address - City:ROBERTS
Practice Address - State:ID
Practice Address - Zip Code:83444-0108
Practice Address - Country:US
Practice Address - Phone:208-228-2435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDXA151417I347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle