Healthcare Provider Details

I. General information

NPI: 1740669498
Provider Name (Legal Business Name): DIAMOND LAKE CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2015
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5939 PORTLAND AVE
MINNEAPOLIS MN
55417-3127
US

IV. Provider business mailing address

5939 PORTLAND AVE
MINNEAPOLIS MN
55417-3127
US

V. Phone/Fax

Practice location:
  • Phone: 612-806-3011
  • Fax:
Mailing address:
  • Phone: 612-806-3011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number52657
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number53530
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number52657
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number52657
License Number StateMN

VIII. Authorized Official

Name: CHUKWUEMEKA ALEXANDER ANYAKE
Title or Position: PHYSICIAN
Credential: MD/MBBS
Phone: 612-806-3011