Provider Demographics
NPI:1922696616
Name:DIAMOND AGE CENTER, LLC
Entity Type:Organization
Organization Name:DIAMOND AGE CENTER, LLC
Other - Org Name:DIAMOND AGE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FARHIYO
Authorized Official - Middle Name:
Authorized Official - Last Name:EGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-407-5030
Mailing Address - Street 1:2403 ASHPOINT ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-6202
Mailing Address - Country:US
Mailing Address - Phone:614-218-3630
Mailing Address - Fax:
Practice Address - Street 1:4889 SINCLAIR RD STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-5433
Practice Address - Country:US
Practice Address - Phone:614-859-2507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0478398Medicaid