Provider Demographics
NPI:1073814448
Name:DIVERSIFIED DIAGNOSTICS
Entity Type:Organization
Organization Name:DIVERSIFIED DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:YORK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-879-0962
Mailing Address - Street 1:2225 W SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 124
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6750
Mailing Address - Country:US
Mailing Address - Phone:817-879-0962
Mailing Address - Fax:800-343-8718
Practice Address - Street 1:2225 W SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 124
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6750
Practice Address - Country:US
Practice Address - Phone:817-879-0962
Practice Address - Fax:800-343-8718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory