Provider Demographics
NPI:1619000593
Name:DIAMOND GROVE CENTER
Entity Type:Organization
Organization Name:DIAMOND GROVE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SWOOPES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-779-0119
Mailing Address - Street 1:2311 HIGHWAY 15 S
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-7071
Mailing Address - Country:US
Mailing Address - Phone:662-779-0119
Mailing Address - Fax:662-779-0126
Practice Address - Street 1:2311 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-7071
Practice Address - Country:US
Practice Address - Phone:662-779-0119
Practice Address - Fax:662-779-0126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS036653336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00020375OtherBLUE CROSS PROVIDER #
MS00330450OtherDIAMOND GROVE CENTER
MS00220411Medicaid
MS00220801Medicaid