MEDICARE: DIADEM HOLISTIC HOME CARE LLC

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1467194167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIADEM HOLISTIC HOME CARE LLC

Provider Business Mailing Address
First Line	:	1147 N BRAGG BLVD
Second Line	:
City	:	SPRING LAKE
State	:	NC
Zip	:	28390-3116
Country	:	US
Telephone Number	:	702-900-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	1147 N BRAGG BLVD
Second Line	:
City	:	SPRING LAKE
State	:	NC
Zip	:	28390-3116
Country	:	US
Telephone Number	:	702-900-2273
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	AJA JULIETTE GEAR
Credential	:
Telephone Number	:	702-900-2273

Provider Enumeration Date	:	04/12/2022
Last Update Date	:	04/12/2022

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