Healthcare Provider Details

I. General information

NPI: 1043315930
Provider Name (Legal Business Name): JAY ERIC DIAMOND PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3734 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63109-1800
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 314-351-7172
  • Fax: 314-351-6885
Mailing address:
  • Phone: 630-575-6250
  • Fax: 630-575-7450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01635
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: