Basic Information
| Provider Information | |||||||||
| NPI: | 1942690789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DATZ | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 6330 RIVERSIDE PLAZA LN NW | ||||||||
| Address2: | 303 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871202681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053127930 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2015 | ||||||||
| LastUpdateDate: | 01/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 4464 | NM | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.