Provider Demographics
NPI:1295035913
Name:DIAMOND STAR MEDICAL LLC
Entity Type:Organization
Organization Name:DIAMOND STAR MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-755-2367
Mailing Address - Street 1:PO BOX 331
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32050-0331
Mailing Address - Country:US
Mailing Address - Phone:904-755-2367
Mailing Address - Fax:
Practice Address - Street 1:1300 HAWKS CREST DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8407
Practice Address - Country:US
Practice Address - Phone:904-755-2367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies