Provider Demographics
NPI:1760017305
Name:DIVERSIFIED MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:DIVERSIFIED MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:SALVATORE
Authorized Official - Last Name:BROCATO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:985-249-1683
Mailing Address - Street 1:106 TENTH ST
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-2409
Mailing Address - Country:US
Mailing Address - Phone:985-249-1683
Mailing Address - Fax:
Practice Address - Street 1:2305 S PURPERA AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5427
Practice Address - Country:US
Practice Address - Phone:225-644-1028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty