Healthcare Provider Details

I. General information

NPI: 1346749942
Provider Name (Legal Business Name): DIVERSE MEDICAL MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5021 TRAIL LAKE DR
PLANO TX
75093-7530
US

IV. Provider business mailing address

82 BECKRIDGE RD
MCMINNVILLE TN
37110-5006
US

V. Phone/Fax

Practice location:
  • Phone: 931-409-4350
  • Fax:
Mailing address:
  • Phone: 931-409-4350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number000765200
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number000765200
License Number StateTX

VIII. Authorized Official

Name: MICHAEL FREY
Title or Position: CEO
Credential:
Phone: 931-409-4350