Provider Demographics
NPI:1407284581
Name:DIAZ, TARA (LAC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:SCHACHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:519 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3006
Mailing Address - Country:US
Mailing Address - Phone:424-258-0738
Mailing Address - Fax:
Practice Address - Street 1:519 MAIN ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245
Practice Address - Country:US
Practice Address - Phone:424-258-0738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-28
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15635171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist