Provider Demographics
NPI:1003865452
Name:DIAMOND REHABILITATION CENTER
Entity Type:Organization
Organization Name:DIAMOND REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DE AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-778-1796
Mailing Address - Street 1:5721 E YANDELL DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3350
Mailing Address - Country:US
Mailing Address - Phone:915-778-1796
Mailing Address - Fax:915-778-8150
Practice Address - Street 1:5721 E YANDELL DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-3350
Practice Address - Country:US
Practice Address - Phone:915-778-1796
Practice Address - Fax:915-778-8150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
0072JWOtherBCBS OF TEXAS
TX454835Medicare ID - Type Unspecified