Provider Demographics
NPI:1700496106
Name:DIAZ MOURE, ILIA DE LOS ANGELES (RBT)
Entity type:Individual
Prefix:
First Name:ILIA
Middle Name:DE LOS ANGELES
Last Name:DIAZ MOURE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 NW 7TH ST APT 305-7
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2259
Mailing Address - Country:US
Mailing Address - Phone:786-663-6125
Mailing Address - Fax:
Practice Address - Street 1:4705 NW 7TH ST APT 305-7
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-2259
Practice Address - Country:US
Practice Address - Phone:786-663-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-129234247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other