Provider Demographics
NPI:1245803170
Name:DIAZ, MAYNOR
Entity type:Individual
Prefix:
First Name:MAYNOR
Middle Name:
Last Name:DIAZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 W REDONDO BEACH BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4175
Mailing Address - Country:US
Mailing Address - Phone:323-241-6730
Mailing Address - Fax:
Practice Address - Street 1:1045 W REDONDO BEACH BLVD STE 300
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4175
Practice Address - Country:US
Practice Address - Phone:323-241-6730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)