Provider Demographics
NPI:1962090670
Name:VEGUILLA DIAZ, CARLOS MIGUEL (LAT, ATC)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:MIGUEL
Last Name:VEGUILLA DIAZ
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-2314
Mailing Address - Country:US
Mailing Address - Phone:787-438-2841
Mailing Address - Fax:
Practice Address - Street 1:1314 MAIN ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-2314
Practice Address - Country:US
Practice Address - Phone:787-438-2841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0072982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer