Provider Demographics
NPI:1740427426
Name:DIAZ, MAYRA L
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:L
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 LENNOX AVE
Mailing Address - Street 2:#221
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2336
Mailing Address - Country:US
Mailing Address - Phone:818-235-2315
Mailing Address - Fax:
Practice Address - Street 1:7201 LENNOX AVE
Practice Address - Street 2:#221
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2336
Practice Address - Country:US
Practice Address - Phone:818-235-2315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-16
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner