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General NPI Number Information
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NPI Number | 1619304573
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Entity Type | Organization
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Legal Business Name | ADVANCED MEDICAL DIAMOND GROUP, LLC
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Dates
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Enumeration Date | 10/08/2013
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Last Update Date | 10/08/2013
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Provider Practice Location Address
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Address Line | 1055 S CONGRESS AVE SUITE 1
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City | DELRAY BEACH
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State | FL
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Zip | 33445-6001
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Country | US
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Telephone | 561-278-9005
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Fax | 561-423-0800
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Provider Business Mailing Address
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Address Line | 1055 S CONGRESS AVE SUITE 1
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City | DELRAY BEACH
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State | FL
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Zip | 33445-6001
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Country | US
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Telephone | 561-278-9005
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Fax | 561-423-0800
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Authorized Official
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Title or Position | OWNER
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Name | DANIEL CHARLESTON
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Credential | D.C.
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Telephone | 561-278-9005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH8492
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License Number State | FL
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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 | ME113665
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License Number State | FL
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