Provider Demographics
NPI:1083128649
Name:DIAZ-TAIROVICH, LUCIANO (LMT)
Entity Type:Individual
Prefix:
First Name:LUCIANO
Middle Name:
Last Name:DIAZ-TAIROVICH
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 1:2 E BLACKWELL ST STE 15
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07801-4645
Mailing Address - Country:US
Mailing Address - Phone:908-220-0732
Mailing Address - Fax:973-361-1360
Practice Address - Street 1:2 E BLACKWELL ST STE 15
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-4645
Practice Address - Country:US
Practice Address - Phone:908-220-0732
Practice Address - Fax:973-361-1360
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-18
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00638600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist