Provider Demographics
NPI:1457026148
Name:LUCERO DIAZ, GUILLERMO (PTA)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:LUCERO DIAZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 AVENUE C SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3243
Mailing Address - Country:US
Mailing Address - Phone:863-268-2903
Mailing Address - Fax:
Practice Address - Street 1:330 AVENUE C SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3243
Practice Address - Country:US
Practice Address - Phone:863-268-2903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28397225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant