Basic Information
| Provider Information | |||||||||
| NPI: | 1740778810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VELASCO | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MARISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23410 TORONJA CORTE | ||||||||
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| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928839369 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1902 ROYALTY DR | ||||||||
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| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096209700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2018 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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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 | 225200000X | PTA49092 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.