Healthcare Provider Details

I. General information

NPI: 1699437624
Provider Name (Legal Business Name): DIANE CARTER MSOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 10/07/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3631 PATSY ANN DR
RICHMOND VA
23234-2951
US

IV. Provider business mailing address

3631 PATSY ANN DR
RICHMOND VA
23234-2951
US

V. Phone/Fax

Practice location:
  • Phone: 303-995-5611
  • Fax:
Mailing address:
  • Phone: 303-995-5611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number0121-000982
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: