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General NPI Number Information
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NPI Number | 1437225513
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Entity Type | Organization
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Legal Business Name | DIAMOND SUPPORTED LIVING SERVICES, INC.
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 330 IVY ST
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City | JACKSONVILLE
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State | FL
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Zip | 32206-6350
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Country | US
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Telephone | 904-307-6844
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Fax | 904-924-1174
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Provider Business Mailing Address
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Address Line | PO BOX 2678
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City | JACKSONVILLE
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State | FL
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Zip | 32203-2678
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Country | US
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Telephone | 904-307-6844
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Fax | 904-924-1174
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | TAZENA E. KENNEDY
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Credential |
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Telephone | 904-307-6844
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 687831896 68783189
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License Number State | FL
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