Provider Demographics
NPI:1013745678
Name:GOMEZ DIAZ, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GOMEZ 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 1:1 CALLE RONDA APT 902
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-2363
Mailing Address - Country:US
Mailing Address - Phone:787-627-0704
Mailing Address - Fax:
Practice Address - Street 1:1450 AVE ASHFORD
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-1590
Practice Address - Country:US
Practice Address - Phone:787-344-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-24
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1091111N00000X
FLCH14734111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor