Provider Demographics
NPI:1497002950
Name:DIAZ, AEIMEE GLORIA (LAC)
Entity Type:Individual
Prefix:
First Name:AEIMEE
Middle Name:GLORIA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W ROOSEVELT ST
Mailing Address - Street 2:SUITE #2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-1376
Mailing Address - Country:US
Mailing Address - Phone:602-307-0888
Mailing Address - Fax:602-307-0888
Practice Address - Street 1:301 W ROOSEVELT ST
Practice Address - Street 2:SUITE #2
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-1376
Practice Address - Country:US
Practice Address - Phone:602-307-0888
Practice Address - Fax:602-307-0888
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0764171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist