Provider Demographics
NPI:1053674812
Name:DIAZ, ARDALIS
Entity Type:Individual
Prefix:
First Name:ARDALIS
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9026 218TH PL
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1337
Mailing Address - Country:US
Mailing Address - Phone:718-264-7250
Mailing Address - Fax:718-264-7922
Practice Address - Street 1:9026 218TH PL
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1337
Practice Address - Country:US
Practice Address - Phone:718-264-7250
Practice Address - Fax:718-264-7922
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator