MEDICARE: DIVERSIFIED COMMUNITY SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12656	OTHER	OH	MACIS UPI

General Provider Information

NPI Number	:	1104056977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSIFIED COMMUNITY SERVICES, INC.

Provider Business Mailing Address
First Line	:	479 SEYMOUR AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43205-2566
Country	:	US
Telephone Number	:	614-252-8688
Fax Number	:	614-252-6787

Provider Business Practice Location Address
First Line	:	479 SEYMOUR AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43205-2566
Country	:	US
Telephone Number	:	614-252-8688
Fax Number	:	614-252-6787

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. FRED HOWARD BORGER
Credential	:
Telephone Number	:	614-252-8688

Provider Enumeration Date	:	07/15/2009
Last Update Date	:	07/15/2009

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