Provider Demographics
NPI:1710281688
Name:DIVERSE MEDICAL LLC
Entity Type:Organization
Organization Name:DIVERSE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILU
Authorized Official - Middle Name:
Authorized Official - Last Name:COSCOLLUELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-325-5768
Mailing Address - Street 1:515 VALLEY ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-1388
Mailing Address - Country:US
Mailing Address - Phone:973-327-2471
Mailing Address - Fax:
Practice Address - Street 1:515 VALLEY ST
Practice Address - Street 2:SUITE 5
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-1388
Practice Address - Country:US
Practice Address - Phone:973-327-2471
Practice Address - Fax:973-327-2483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6471120001Medicare NSC