Basic Information
| Provider Information | |||||||||
| NPI: | 1194314476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | CARLOS | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 ROUTE 9 N STE 410 | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070951003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018017141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 323 MARIN BLVD | ||||||||
| Address2: | |||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073023698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5512224520 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2021 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01987100 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.