Provider Demographics
NPI:1750096905
Name:CORDOBA, DIANA V (LMT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:V
Last Name:CORDOBA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3714 WILLIS RD APT 11
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-4720
Mailing Address - Country:US
Mailing Address - Phone:706-393-0525
Mailing Address - Fax:
Practice Address - Street 1:205 N 7TH ST
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-4233
Practice Address - Country:US
Practice Address - Phone:334-737-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6122225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist