Provider Demographics
NPI:1992498513
Name:DIAZ, JUAN CARLOS
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
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 1:3152 BLUE DIRT CIR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-2506
Mailing Address - Country:US
Mailing Address - Phone:915-922-0313
Mailing Address - Fax:
Practice Address - Street 1:3152 BLUE DIRT CIR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-2506
Practice Address - Country:US
Practice Address - Phone:915-922-0313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLHOC23-00038311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home