Healthcare Provider Details

I. General information

NPI: 1962095737
Provider Name (Legal Business Name): DILIGENT MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 EAGLE ROCK CT
CHESTER VA
23831-7051
US

IV. Provider business mailing address

2605 EAGLE ROCK CT
CHESTER VA
23831-7051
US

V. Phone/Fax

Practice location:
  • Phone: 804-253-7075
  • Fax:
Mailing address:
  • Phone: 804-253-7075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. OLANDO WAYNE FULLER
Title or Position: OWNER
Credential: QMHP
Phone: 804-253-7075