Provider Demographics
NPI:1316830847
Name:BACK, DIVA
Entity type:Individual
Prefix:
First Name:DIVA
Middle Name:
Last Name:BACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4539 N 22ND ST STE N
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4639
Mailing Address - Country:US
Mailing Address - Phone:520-488-0614
Mailing Address - Fax:
Practice Address - Street 1:11788 E ARABELLE DR
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-0709
Practice Address - Country:US
Practice Address - Phone:520-488-0614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health