Basic Information
| Provider Information | |||||||||
| NPI: | 1487311486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ GARCIA | ||||||||
| FirstName: | JESUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45046 PROMISE RD | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925321500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092723221 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12555 LAKEWOOD BLVD STE F | ||||||||
| Address2: | |||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902422771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629234704 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2021 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 51544 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.