=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346102878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAMOND GARDEN HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2025
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15319 SPINNING AVE
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90249-4143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-274-1809
-----------------------------------------------------
Fax | 323-978-6018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15319 SPINNING AVE
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90249-4143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-274-1809
-----------------------------------------------------
Fax | 323-978-6018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JOSEPH JOSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-274-1809
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------