Individual
RAUL BERNARDO DIESTRA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1118 OAK ST SE, SALEM, OR 97301-4019
(503) 358-4850
Mailing address
1118 OAK ST SE, SALEM, OR 97301-4019
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
122994
—
OR
Enumeration date
04/02/2018
Last updated
04/04/2018
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