Provider Demographics
NPI:1780652693
Name:DIAMOND FAMILY PRACTICE, PLLC
Entity Type:Organization
Organization Name:DIAMOND FAMILY PRACTICE, PLLC
Other - Org Name:LAKE JEANETTE URGENT CARE, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORGANIZING MEMBER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOAZE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:336-601-0812
Mailing Address - Street 1:1309 LEES CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2601
Mailing Address - Country:US
Mailing Address - Phone:336-286-5505
Mailing Address - Fax:336-286-5583
Practice Address - Street 1:1309 LEES CHAPEL RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2601
Practice Address - Country:US
Practice Address - Phone:336-286-5505
Practice Address - Fax:336-286-5583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty