Provider Demographics
NPI:1851838114
Name:DIAZ, DONNA BOURGEOIS (DC)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:BOURGEOIS
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CECIL PL APT B
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-6719
Mailing Address - Country:US
Mailing Address - Phone:337-967-2768
Mailing Address - Fax:
Practice Address - Street 1:4030 BIRCH ST STE 107
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2291
Practice Address - Country:US
Practice Address - Phone:949-752-5533
Practice Address - Fax:949-752-5532
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 33757111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor