Provider Demographics
NPI:1275811598
Name:DIAMOND MANOR ADULT CARE
Entity Type:Organization
Organization Name:DIAMOND MANOR ADULT CARE
Other - Org Name:DIAMOND MANOR ADULT CARE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA VIRGINIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-703-7396
Mailing Address - Street 1:4356 W ST CATHERINE AVE
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-6233
Mailing Address - Country:US
Mailing Address - Phone:480-703-7396
Mailing Address - Fax:602-237-1624
Practice Address - Street 1:7330 W. GETTY DRIVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043
Practice Address - Country:US
Practice Address - Phone:480-703-7396
Practice Address - Fax:602-237-1624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL7047H311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home