Provider Demographics
NPI:1629580329
Name:DIAZ, VINCENT JOHN
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:JOHN
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MEDICAL DR STE 2
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4946
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2251 E 3000 N
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-7155
Practice Address - Country:US
Practice Address - Phone:801-678-9871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician