Provider Demographics
NPI:1538510367
Name:DIAMOND STATE MOBILITY LLC
Entity Type:Organization
Organization Name:DIAMOND STATE MOBILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEAL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-559-5652
Mailing Address - Street 1:602 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MARCUS HOOK
Mailing Address - State:PA
Mailing Address - Zip Code:19061-4719
Mailing Address - Country:US
Mailing Address - Phone:215-908-3239
Mailing Address - Fax:
Practice Address - Street 1:602 MARKET ST
Practice Address - Street 2:
Practice Address - City:MARCUS HOOK
Practice Address - State:PA
Practice Address - Zip Code:19061-4719
Practice Address - Country:US
Practice Address - Phone:215-908-3239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6421913171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Multi-Specialty