Provider Demographics
NPI:1558113910
Name:DIVERSE IPA INC
Entity Type:Organization
Organization Name:DIVERSE IPA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:QI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:929-629-8277
Mailing Address - Street 1:3712 PRINCE ST STE 8C
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3712 PRINCE ST STE 8C
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4652
Practice Address - Country:US
Practice Address - Phone:929-629-8277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization