Provider Demographics
NPI:1548387392
Name:DIAMOND HEART INC
Entity Type:Organization
Organization Name:DIAMOND HEART INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ATEF
Authorized Official - Middle Name:FARAH
Authorized Official - Last Name:MITRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-767-0557
Mailing Address - Street 1:PO BOX 290274
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129
Mailing Address - Country:US
Mailing Address - Phone:386-767-0557
Mailing Address - Fax:386-767-3251
Practice Address - Street 1:3959 S NOVA RD
Practice Address - Street 2:SUITE #1
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129
Practice Address - Country:US
Practice Address - Phone:386-767-0557
Practice Address - Fax:386-767-3251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7670Medicare ID - Type Unspecified