Provider Demographics
NPI:1437864253
Name:DIAZ, BEAU DUNSTAN REYES (LVN)
Entity Type:Individual
Prefix:MR
First Name:BEAU
Middle Name:DUNSTAN REYES
Last Name:DIAZ
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 GRAMERCY AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-5431
Mailing Address - Country:US
Mailing Address - Phone:424-552-5314
Mailing Address - Fax:
Practice Address - Street 1:2803 GRAMERCY AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-5431
Practice Address - Country:US
Practice Address - Phone:424-552-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA728542164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse