Provider Demographics
NPI:1407444730
Name:DIEZ MEDICAL LLC
Entity Type:Organization
Organization Name:DIEZ MEDICAL LLC
Other - Org Name:DIEZ MEDICAL LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:D
Authorized Official - Last Name:DIEZ
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:786-253-9513
Mailing Address - Street 1:16881 SW 278TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33031-2745
Mailing Address - Country:US
Mailing Address - Phone:786-253-9513
Mailing Address - Fax:
Practice Address - Street 1:1414 NW 107TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:FL
Practice Address - Zip Code:33172-2741
Practice Address - Country:US
Practice Address - Phone:786-253-9513
Practice Address - Fax:786-933-6651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty