Basic Information
| Provider Information | |||||||||
| NPI: | 1750823910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | CASTILLO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1667 VEJAR ST | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917662530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095683126 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3881 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900621105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232904349 | ||||||||
| FaxNumber: | 3232938159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2016 | ||||||||
| LastUpdateDate: | 12/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT37201 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.