Healthcare Provider Details

I. General information

NPI: 1447984836
Provider Name (Legal Business Name): DIAMOND STATE CHIROPRACTIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 TWIN C LN STE 201
NEWARK DE
19713-2159
US

IV. Provider business mailing address

1101 TWIN C LN STE 201
NEWARK DE
19713-2159
US

V. Phone/Fax

Practice location:
  • Phone: 302-892-9355
  • Fax: 302-892-3494
Mailing address:
  • Phone: 302-892-9355
  • Fax: 302-892-3494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: TODD BOGOS
Title or Position: OWNER/PRESIDENT
Credential: D.C.
Phone: 302-892-9355