Provider Demographics
NPI:1346523875
Name:DIAMOND URGENT CARE AND PAIN CLINIC CORPORATION
Entity Type:Organization
Organization Name:DIAMOND URGENT CARE AND PAIN CLINIC CORPORATION
Other - Org Name:DIAMOND MEDICAL CENTER CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNSPENCER
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHINIHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-283-4014
Mailing Address - Street 1:1650 W SAND LAKE RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-7681
Mailing Address - Country:US
Mailing Address - Phone:407-283-4014
Mailing Address - Fax:407-601-5988
Practice Address - Street 1:1650 W SAND LAKE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-7681
Practice Address - Country:US
Practice Address - Phone:407-283-4014
Practice Address - Fax:407-601-5988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279671600Medicaid
FL279671600Medicaid