Basic Information
| Provider Information | |||||||||
| NPI: | 1487964656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAN JUAN | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | LIZBETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | QMHA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 189 E ELM CT | ||||||||
| Address2: | |||||||||
| City: | GERVAIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970269780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712180951 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2421 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033612720 | ||||||||
| FaxNumber: | 5035854990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2010 | ||||||||
| LastUpdateDate: | 10/20/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.