Healthcare Provider Details

I. General information

NPI: 1437463064
Provider Name (Legal Business Name): DIAMOND JANE'S, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 S HALE ST
GRANTSVILLE UT
84029-9546
US

IV. Provider business mailing address

345 S HALE ST
GRANTSVILLE UT
84029-9546
US

V. Phone/Fax

Practice location:
  • Phone: 435-809-3918
  • Fax:
Mailing address:
  • Phone: 435-809-3918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2009-ALII-90309
License Number StateUT

VIII. Authorized Official

Name: MR. MAUREEN B PETERSON
Title or Position: OWNER
Credential:
Phone: 435-579-4402