=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225544570
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAMOND HEALTHCARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2017
-----------------------------------------------------
Last Update Date | 01/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 N SHILOH RD STE 212
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75042-6694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-626-0152
-----------------------------------------------------
Fax | 469-626-0153
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 N SHILOH RD STE 212
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75042-6694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-626-0152
-----------------------------------------------------
Fax | 469-626-0153
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | IFEOMA EZENNIA
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 469-626-0152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 018598
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------