Healthcare Provider Details

I. General information

NPI: 1821708454
Provider Name (Legal Business Name): DIAMOND SOL WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2127 W 5TH PL STE A
TEMPE AZ
85281-7228
US

IV. Provider business mailing address

2127 W 5TH PL STE A
TEMPE AZ
85281-7228
US

V. Phone/Fax

Practice location:
  • Phone: 602-488-1172
  • Fax:
Mailing address:
  • Phone: 602-488-1172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOEL ISAAC LOPEZ
Title or Position: CEO
Credential: MA
Phone: 602-488-1172