Provider Demographics
NPI:1043884166
Name:DIAZ, EDWIN ANDRES (LMT)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:ANDRES
Last Name:DIAZ
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 VILLA FONTANA VIA
Mailing Address - Street 2:4KS-16
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983
Mailing Address - Country:US
Mailing Address - Phone:787-647-7544
Mailing Address - Fax:
Practice Address - Street 1:VILLA FONTANA VIA 46
Practice Address - Street 2:4KS-16
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983
Practice Address - Country:US
Practice Address - Phone:787-647-7544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR933225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist