Healthcare Provider Details

I. General information

NPI: 1568939486
Provider Name (Legal Business Name): DIVERSE IMAGES MANAGEMENT SERVICES LLC,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3724 MARTIN LUTHER KING DR SW
ATLANTA GA
30331-3600
US

IV. Provider business mailing address

PO BOX 366037
ATLANTA GA
30336-6037
US

V. Phone/Fax

Practice location:
  • Phone: 678-886-0284
  • Fax:
Mailing address:
  • Phone: 678-886-0284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: DEEANN JOHNSON
Title or Position: SPECIALIST
Credential:
Phone: 678-886-0284