Provider Demographics
NPI:1669797437
Name:BLUE DIAMOND HEALTH CARE LLC
Entity type:Organization
Organization Name:BLUE DIAMOND HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:VACRACOS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:219-765-3431
Mailing Address - Street 1:2749 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5246
Mailing Address - Country:US
Mailing Address - Phone:773-292-9660
Mailing Address - Fax:
Practice Address - Street 1:2749 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5246
Practice Address - Country:US
Practice Address - Phone:773-292-9660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty