Provider Demographics
NPI:1659463297
Name:DIAZ, EDEL RICARDO (DC)
Entity Type:Individual
Prefix:
First Name:EDEL
Middle Name:RICARDO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 CALLE CESAR GONZALEZ
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-2652
Mailing Address - Country:US
Mailing Address - Phone:787-759-9605
Mailing Address - Fax:787-754-6958
Practice Address - Street 1:508 CALLE CESAR GONZALEZ
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-2652
Practice Address - Country:US
Practice Address - Phone:787-759-9605
Practice Address - Fax:787-754-6958
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0270111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician