Provider Demographics
NPI:1861402646
Name:DIAZ, JEANETTE (DC)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 430746
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33243-0746
Mailing Address - Country:US
Mailing Address - Phone:786-380-6652
Mailing Address - Fax:
Practice Address - Street 1:1500 SW 27TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2043
Practice Address - Country:US
Practice Address - Phone:305-448-1500
Practice Address - Fax:305-448-8681
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9231111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380201900Medicaid
FL382305900Medicaid
FL382305900Medicaid