Healthcare Provider Details

I. General information

NPI: 1740828250
Provider Name (Legal Business Name): ANDREW DIAMOND DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 POWELL DR
DUNDEE MI
48131-8644
US

IV. Provider business mailing address

100 POWELL DR
DUNDEE MI
48131-8644
US

V. Phone/Fax

Practice location:
  • Phone: 517-266-1481
  • Fax:
Mailing address:
  • Phone: 517-266-1481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501017116
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: