Provider Demographics
NPI:1053543520
Name:BLUE DIAMOND HEALTH CARE LLC
Entity type:Organization
Organization Name:BLUE DIAMOND HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:VACRACOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-292-9660
Mailing Address - Street 1:8606 DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-1776
Mailing Address - Country:US
Mailing Address - Phone:219-765-3431
Mailing Address - Fax:
Practice Address - Street 1:2749 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5246
Practice Address - Country:US
Practice Address - Phone:773-292-9660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085675Medicaid