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General NPI Number Information
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NPI Number | 1346749942
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Entity Type | Organization
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Legal Business Name | DIVERSE MEDICAL MANAGEMENT, INC.
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Dates
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Enumeration Date | 02/08/2018
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Last Update Date | 02/08/2018
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Provider Practice Location Address
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Address Line | 5021 TRAIL LAKE DR
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City | PLANO
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State | TX
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Zip | 75093-7530
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Country | US
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Telephone | 931-409-4350
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Fax |
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Provider Business Mailing Address
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Address Line | 82 BECKRIDGE RD
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City | MCMINNVILLE
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State | TN
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Zip | 37110-5006
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Country | US
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Telephone | 931-409-4350
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MICHAEL FREY
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Credential |
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Telephone | 931-409-4350
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 000765200
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 000765200
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License Number State | TX
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