Healthcare Provider Details

I. General information

NPI: 1750188728
Provider Name (Legal Business Name): DIVERSA MEDICAL SUPPLY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2025
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4695 RIDGE RD
WADSWORTH OH
44281-9758
US

IV. Provider business mailing address

4695 RIDGE RD
WADSWORTH OH
44281-9758
US

V. Phone/Fax

Practice location:
  • Phone: 330-239-0969
  • Fax:
Mailing address:
  • Phone: 330-239-0969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: JOHN R. JAMES JR.
Title or Position: GEN MGR
Credential:
Phone: 330-239-0969