Provider Demographics
NPI:1558113910
Name:DIVERSE IPA INC
Entity type:Organization
Organization Name:DIVERSE IPA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BAOLI
Authorized Official - Middle Name:
Authorized Official - Last Name:ZHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-561-0505
Mailing Address - Street 1:13229 BLOSSOM AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-4915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13229 BLOSSOM AVE FL 1
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-4915
Practice Address - Country:US
Practice Address - Phone:917-561-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization