Provider Demographics
NPI:1164046926
Name:DIVERSITY HEALTH SERVICE LLC
Entity Type:Organization
Organization Name:DIVERSITY HEALTH SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:ARAB
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:612-834-5913
Mailing Address - Street 1:7900 INTERNATIONAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-2562
Mailing Address - Country:US
Mailing Address - Phone:612-834-5913
Mailing Address - Fax:
Practice Address - Street 1:7900 INTERNATIONAL DR STE 300
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-2562
Practice Address - Country:US
Practice Address - Phone:612-834-5913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-07
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities