Healthcare Provider Details

I. General information

NPI: 1275811598
Provider Name (Legal Business Name): DIAMOND MANOR ADULT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 W. GETTY DRIVE
PHOENIX AZ
85043
US

IV. Provider business mailing address

4356 W ST CATHERINE AVE
LAVEEN AZ
85339-6233
US

V. Phone/Fax

Practice location:
  • Phone: 480-703-7396
  • Fax: 602-237-1624
Mailing address:
  • Phone: 480-703-7396
  • Fax: 602-237-1624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAL7047H
License Number StateAZ

VIII. Authorized Official

Name: MRS. MARIA VIRGINIA N CORDOVA
Title or Position: MANAGER/OWNER
Credential:
Phone: 480-703-7396