Provider Demographics
NPI:1891172367
Name:DIAMOND LIFE SERVICES CHARITY INCORPORATED
Entity Type:Organization
Organization Name:DIAMOND LIFE SERVICES CHARITY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-752-2712
Mailing Address - Street 1:PO BOX 896
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23607-0896
Mailing Address - Country:US
Mailing Address - Phone:757-594-6251
Mailing Address - Fax:757-890-3044
Practice Address - Street 1:935 VIRGILINA AVENUE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23503
Practice Address - Country:US
Practice Address - Phone:757-752-2710
Practice Address - Fax:757-890-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health