Basic Information
| Provider Information | |||||||||
| NPI: | 1619378171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ-HERNANDEZ | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 RAPHAEL DR. | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563625673 | ||||||||
| FaxNumber: | 9563622038 | ||||||||
| Practice Location | |||||||||
| Address1: | 5500 RAPHAEL DR. | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563625673 | ||||||||
| FaxNumber: | 9563622038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2014 | ||||||||
| LastUpdateDate: | 11/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT83433 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 344862301 | 05 | TX | MEDICAID |