Provider Demographics
NPI:1396744694
Name:DIAMEDIX HEALTHCARE LLC
Entity type:Organization
Organization Name:DIAMEDIX HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:EISELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-747-8900
Mailing Address - Street 1:4860 COX RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9250
Mailing Address - Country:US
Mailing Address - Phone:804-747-8900
Mailing Address - Fax:804-747-8910
Practice Address - Street 1:4860 COX RD
Practice Address - Street 2:SUITE 300
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-9250
Practice Address - Country:US
Practice Address - Phone:804-747-8900
Practice Address - Fax:804-747-8910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
VAD07211000332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDM1363Medicaid
VA5032200001Medicare NSC
SCDM1363Medicaid