1407444730 NPI number — DIEZ MEDICAL LLC

Table of content: (NPI 1407444730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407444730 NPI number — DIEZ MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIEZ MEDICAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1407444730
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16881 SW 278TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMESTEAD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33031-2745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-253-9513
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1414 NW 107TH AVE STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SWEETWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33172-2741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-253-9513
Provider Business Practice Location Address Fax Number:
786-933-6651
Provider Enumeration Date:
01/04/2021

Additional Information

Authorized Official

Authorized Official Last Name:
DIEZ
Authorized Official First Name:
BORIS
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
786-253-9513

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 111341100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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