Provider Demographics
NPI:1801224910
Name:DIAMOND ONE HEALTHCARE
Entity Type:Organization
Organization Name:DIAMOND ONE HEALTHCARE
Other - Org Name:HOME HEALTHCARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:JR
Authorized Official - Credentials:ULITMATE MEDICAL ACA
Authorized Official - Phone:901-362-6015
Mailing Address - Street 1:3514 CLEARBROOK ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-5547
Mailing Address - Country:US
Mailing Address - Phone:901-362-6015
Mailing Address - Fax:901-405-5106
Practice Address - Street 1:3514 CLEARBROOK ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-5547
Practice Address - Country:US
Practice Address - Phone:901-362-6015
Practice Address - Fax:901-405-5106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN113004427302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN113004427Medicaid