MEDICARE: DIAMOND ONE HEALTHCARE

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	302F00000X	Exclusive Provider Organization	113004427	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801224910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIAMOND ONE HEALTHCARE

Provider Business Mailing Address
First Line	:	3514 CLEARBROOK ST
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38118-5547
Country	:	US
Telephone Number	:	901-362-6015
Fax Number	:	901-405-5106

Provider Business Practice Location Address
First Line	:	3514 CLEARBROOK ST
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38118-5547
Country	:	US
Telephone Number	:	901-362-6015
Fax Number	:	901-405-5106

Authorized Official
Title or Position	:	CEO
Name	:	MR. CHARLES EDWARD REYNOLDS JR.
Credential	:	ULITMATE MEDICAL ACA
Telephone Number	:	901-362-6015

Provider Enumeration Date	:	10/29/2013
Last Update Date	:	10/29/2013

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Directions to “DIAMOND ONE HEALTHCARE ” Practice Location

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