Provider Demographics
NPI:1265049514
Name:DIAMOND EDGE HEALTHCARE, LLC
Entity type:Organization
Organization Name:DIAMOND EDGE HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WENTZELL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:603-566-4493
Mailing Address - Street 1:6 CHENEY DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NH
Mailing Address - Zip Code:03051-3903
Mailing Address - Country:US
Mailing Address - Phone:603-566-4493
Mailing Address - Fax:
Practice Address - Street 1:10 RESEARCH PL STE 202
Practice Address - Street 2:
Practice Address - City:NORTH CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01863-2439
Practice Address - Country:US
Practice Address - Phone:978-275-1390
Practice Address - Fax:978-275-1394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service