Provider Demographics
NPI:1861272759
Name:ORTIZ DIAZ, VICTOR EMANUEL
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:EMANUEL
Last Name:ORTIZ DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:VICTOR
Other - Middle Name:EMANUEL
Other - Last Name:ORTIZ DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:703 E MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-8695
Mailing Address - Country:US
Mailing Address - Phone:270-699-2323
Mailing Address - Fax:270-699-2323
Practice Address - Street 1:703 E MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-8695
Practice Address - Country:US
Practice Address - Phone:270-699-2323
Practice Address - Fax:270-699-2323
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY286517111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor