Provider Demographics
NPI:1912568338
Name:DIAZ, LUIS EDUARDO
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:EDUARDO
Last Name:DIAZ
Suffix:
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 1:1055 W HENDERSON AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-1490
Mailing Address - Country:US
Mailing Address - Phone:559-623-0900
Mailing Address - Fax:
Practice Address - Street 1:1055 W HENDERSON AVE STE 2
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-1490
Practice Address - Country:US
Practice Address - Phone:559-623-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
373H00000X
CAAR471540390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty