Provider Demographics
NPI:1366706319
Name:DIAMOND MEDICAL SPA AND VEIN, PC
Entity type:Organization
Organization Name:DIAMOND MEDICAL SPA AND VEIN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:L
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-505-5372
Mailing Address - Street 1:3170 E 53RD ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3864
Mailing Address - Country:US
Mailing Address - Phone:563-505-5372
Mailing Address - Fax:
Practice Address - Street 1:3170 E 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3864
Practice Address - Country:US
Practice Address - Phone:563-505-5372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-076186207V00000X
IA27540207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty