Provider Demographics
NPI:1780345173
Name:RAW DYMONDZ
Entity type:Organization
Organization Name:RAW DYMONDZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRANIAL PROTHESIS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-896-6685
Mailing Address - Street 1:2096 MCPHERSON RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-8618
Mailing Address - Country:US
Mailing Address - Phone:901-896-6685
Mailing Address - Fax:901-896-6685
Practice Address - Street 1:2096 MCPHERSON RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-8618
Practice Address - Country:US
Practice Address - Phone:901-896-6685
Practice Address - Fax:901-896-6685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier