Provider Demographics
NPI:1174089932
Name:DIAMOND, COREY (DC34416)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:DC34416
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 CAMINO DE LOS MARES STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2829
Mailing Address - Country:US
Mailing Address - Phone:949-240-1334
Mailing Address - Fax:949-240-4434
Practice Address - Street 1:629 CAMINO DE LOS MARES STE 104
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2829
Practice Address - Country:US
Practice Address - Phone:949-240-1334
Practice Address - Fax:949-240-4434
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC34416111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor