Provider Demographics
NPI:1669210811
Name:DIAZ REYES, INGRID KERRY (LAC)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:KERRY
Last Name:DIAZ REYES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 HAZELNUT CT
Mailing Address - Street 2:
Mailing Address - City:DRIFTWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:78619-4489
Mailing Address - Country:US
Mailing Address - Phone:716-361-8632
Mailing Address - Fax:
Practice Address - Street 1:151 KIRKHAM CIR
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-9703
Practice Address - Country:US
Practice Address - Phone:512-893-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC02142171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty