MEDICARE: DIVERSE MEDICAL MANAGEMENT, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center	000765200	TX
2	207Q00000X	Family Medicine Physician	000765200	TX

General Provider Information

NPI Number	:	1346749942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSE MEDICAL MANAGEMENT, INC.

Provider Business Mailing Address
First Line	:	82 BECKRIDGE RD
Second Line	:
City	:	MCMINNVILLE
State	:	TN
Zip	:	37110-5006
Country	:	US
Telephone Number	:	931-409-4350
Fax Number	:

Provider Business Practice Location Address
First Line	:	5021 TRAIL LAKE DR
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-7530
Country	:	US
Telephone Number	:	931-409-4350
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL FREY
Credential	:
Telephone Number	:	931-409-4350

Provider Enumeration Date	:	02/08/2018
Last Update Date	:	02/08/2018

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