Provider Demographics
NPI:1720737885
Name:DIEGO, MARIVIC LUCENA
Entity Type:Individual
Prefix:
First Name:MARIVIC
Middle Name:LUCENA
Last Name:DIEGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-8923
Mailing Address - Fax:
Practice Address - Street 1:4959 BILL GARDNER PKWY STE 109
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-2915
Practice Address - Country:US
Practice Address - Phone:770-914-9285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist