Provider Demographics
NPI:1932585965
Name:BLACK DIAMOND MED SPA
Entity Type:Organization
Organization Name:BLACK DIAMOND MED SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAFTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-403-2552
Mailing Address - Street 1:18730 STONE OAK PKWY
Mailing Address - Street 2:STE 106
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4140
Mailing Address - Country:US
Mailing Address - Phone:210-403-2552
Mailing Address - Fax:210-403-2144
Practice Address - Street 1:18730 STONE OAK PKWY
Practice Address - Street 2:STE 106
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4140
Practice Address - Country:US
Practice Address - Phone:210-403-2552
Practice Address - Fax:210-403-2144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty