MEDICARE: DIAMOND JORDAN PTA

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	225200000X	Physical Therapy Assistant	25497	FL

General Provider Information

NPI Number	:	1598155897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIAMOND JORDAN PTA

Provider Business Mailing Address
First Line	:	6675 LAKE ISLAND DR
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-7905
Country	:	US
Telephone Number	:	205-799-1278
Fax Number	:

Provider Business Practice Location Address
First Line	:	8993 OKEECHOBEE BLVD
Second Line	:	STE 100
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-5144
Country	:	US
Telephone Number	:	561-478-3702
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2015
Last Update Date	:	01/26/2015

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