Provider Demographics
NPI:1780980391
Name:DIAMOND SPRINGS WELLNESS CENTER PC
Entity type:Organization
Organization Name:DIAMOND SPRINGS WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:435-657-1777
Mailing Address - Street 1:210 E MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIDWAY
Mailing Address - State:UT
Mailing Address - Zip Code:84049-6806
Mailing Address - Country:US
Mailing Address - Phone:435-657-1777
Mailing Address - Fax:435-657-0098
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MIDWAY
Practice Address - State:UT
Practice Address - Zip Code:84049-6806
Practice Address - Country:US
Practice Address - Phone:435-657-1777
Practice Address - Fax:435-657-0098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT180388-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE99335Medicare UPIN