Provider Demographics
NPI:1669139945
Name:DIAZ MEDICAL GROUP INC
Entity type:Organization
Organization Name:DIAZ MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KING NINO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:909-217-8633
Mailing Address - Street 1:14550 ARCHWOOD ST STE B
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-4628
Mailing Address - Country:US
Mailing Address - Phone:909-217-8633
Mailing Address - Fax:
Practice Address - Street 1:14550 ARCHWOOD ST STE B
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4628
Practice Address - Country:US
Practice Address - Phone:909-217-8633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center