Provider Demographics
NPI:1386246940
Name:DIAMOND STATE PRIMARY CARE, LLC
Entity type:Organization
Organization Name:DIAMOND STATE PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IMELYN
Authorized Official - Middle Name:FERNANDEZ
Authorized Official - Last Name:LAHEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-838-2210
Mailing Address - Street 1:1400 PEOPLES PLZ STE 305
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-5708
Mailing Address - Country:US
Mailing Address - Phone:302-838-2210
Mailing Address - Fax:302-838-2129
Practice Address - Street 1:1400 PEOPLES PLZ STE 305
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-5708
Practice Address - Country:US
Practice Address - Phone:302-838-2210
Practice Address - Fax:302-838-2129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-09
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty