Provider Demographics
NPI:1851573331
Name:DIMOND MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:DIMOND MEDICAL CLINIC, LLC
Other - Org Name:LAKE OTIS MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:MACLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-341-7757
Mailing Address - Street 1:300 E DIMOND BLVD
Mailing Address - Street 2:#12
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1908
Mailing Address - Country:US
Mailing Address - Phone:907-341-7757
Mailing Address - Fax:
Practice Address - Street 1:4001 LAKE OTIS PKWY
Practice Address - Street 2:#100
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5211
Practice Address - Country:US
Practice Address - Phone:907-561-7757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK905735207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty