1215359781 NPI number — ALEXANDER DIAZ LAC

Table of content: ALEXANDER DIAZ LAC (NPI 1215359781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215359781 NPI number — ALEXANDER DIAZ LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIAZ
Provider First Name:
ALEXANDER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215359781
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1551 PROFESSIONAL LANE, SUITE 180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGMONT
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-772-0598
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1760 SW 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORVALLIS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97333-1725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-380-1327
Provider Business Practice Location Address Fax Number:
888-972-4948
Provider Enumeration Date:
01/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  190492 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171100000X , with the licence number: 1932 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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