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General NPI Number Information
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NPI Number | 1548387392
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Entity Type | Organization
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Legal Business Name | DIAMOND HEART INC
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3959 S NOVA RD SUITE #1
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City | PORT ORANGE
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State | FL
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Zip | 32129
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Country | US
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Telephone | 386-767-0557
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Fax | 386-767-3251
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Provider Business Mailing Address
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Address Line | PO BOX 290274
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City | PORT ORANGE
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State | FL
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Zip | 32129
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Country | US
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Telephone | 386-767-0557
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Fax | 386-767-3251
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Authorized Official
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Title or Position | PRESIDENT
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Name | ATEF FARAH MITRY
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Credential |
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Telephone | 386-767-0557
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT10588
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License Number State | FL
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