MEDICARE: DIAMOND RUSSELL

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1639029804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIAMOND RUSSELL

Provider Business Mailing Address
First Line	:	1880 LOWELL AVE
Second Line	:
City	:	LIMA
State	:	OH
Zip	:	45805-3126
Country	:	US
Telephone Number	:	567-825-6899
Fax Number	:

Provider Business Practice Location Address
First Line	:	1880 LOWELL AVE
Second Line	:
City	:	LIMA
State	:	OH
Zip	:	45805-3126
Country	:	US
Telephone Number	:	567-825-6899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2026
Last Update Date	:	01/29/2026

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Directions to “ DIAMOND RUSSELL ” Practice Location

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