Provider Demographics
NPI:1417704230
Name:DIETRICH, ROY HENRY III
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:HENRY
Last Name:DIETRICH
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24910 LAS BRISAS RD STE 117
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4035
Mailing Address - Country:US
Mailing Address - Phone:951-465-3664
Mailing Address - Fax:
Practice Address - Street 1:24910 LAS BRISAS RD STE 117
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-4035
Practice Address - Country:US
Practice Address - Phone:951-465-3664
Practice Address - Fax:951-972-8551
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker