Provider Demographics
NPI:1407543176
Name:DIAMOND ORTHOTIC LABORATORY
Entity Type:Organization
Organization Name:DIAMOND ORTHOTIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-724-6400
Mailing Address - Street 1:7859 EL CAJON BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-0602
Mailing Address - Country:US
Mailing Address - Phone:619-724-6400
Mailing Address - Fax:
Practice Address - Street 1:7859 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-0602
Practice Address - Country:US
Practice Address - Phone:619-724-6400
Practice Address - Fax:619-724-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory