Basic Information
| Provider Information | |||||||||
| NPI: | 1366925406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES DIAZ | ||||||||
| FirstName: | ODALIS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | REYES DIAZ | ||||||||
| OtherFirstName: | ODALIS | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RPT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | URB VENUS GARDENS | ||||||||
| Address2: | 1760 CALLE PELIUX | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7873615449 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | COOP CIUDAD UNIVERSITARIA | ||||||||
| Address2: | G10 AVE PERIFERAL | ||||||||
| City: | TRUJILLO ALTO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009762104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877608405 | ||||||||
| FaxNumber: | 7877608484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2018 | ||||||||
| LastUpdateDate: | 09/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 000698 | PR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.