Provider Demographics
NPI:1770978413
Name:DIAMOND MEDICAL CARE LLC
Entity type:Organization
Organization Name:DIAMOND MEDICAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:816-295-1606
Mailing Address - Street 1:1101 NW PAMELA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-7841
Mailing Address - Country:US
Mailing Address - Phone:816-295-1606
Mailing Address - Fax:
Practice Address - Street 1:1101 NW PAMELA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GRAIN VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64029-7841
Practice Address - Country:US
Practice Address - Phone:816-295-1606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9G82261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1588604979Medicaid