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General NPI Number Information
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NPI Number | 1558113910
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Entity Type | Organization
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Legal Business Name | DIVERSE IPA INC
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Dates
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Enumeration Date | 04/01/2024
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Last Update Date | 10/01/2024
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Provider Practice Location Address
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Address Line | 13229 BLOSSOM AVE FL 1
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City | FLUSHING
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State | NY
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Zip | 11355-4915
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Country | US
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Telephone | 917-561-0505
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Fax |
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Provider Business Mailing Address
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Address Line | 13229 BLOSSOM AVE FL 1
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City | FLUSHING
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State | NY
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Zip | 11355-4915
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. BAOLI ZHANG
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Credential |
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Telephone | 917-561-0505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number |
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License Number State |
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