Provider Demographics
NPI:1790741742
Name:DIAZ, CHRIS ALFONSO (ATC)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:ALFONSO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-6949
Mailing Address - Country:US
Mailing Address - Phone:812-760-9431
Mailing Address - Fax:812-833-2090
Practice Address - Street 1:700 HARRIETT ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IN
Practice Address - Zip Code:47620-2031
Practice Address - Country:US
Practice Address - Phone:812-833-5928
Practice Address - Fax:812-833-2090
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000002A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer