Provider Demographics
NPI:1790449981
Name:DIAMOND STATE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:DIAMOND STATE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:501-590-7376
Mailing Address - Street 1:11220 N RODNEY PARHAM RD STE 6
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-4161
Mailing Address - Country:US
Mailing Address - Phone:501-246-3844
Mailing Address - Fax:501-246-3188
Practice Address - Street 1:11220 N RODNEY PARHAM RD STE 6
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-4161
Practice Address - Country:US
Practice Address - Phone:501-246-3844
Practice Address - Fax:501-246-3188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty