Provider Demographics
NPI:1013330828
Name:DIAMAL, WENDELL JR (LMT)
Entity type:Individual
Prefix:MR
First Name:WENDELL
Middle Name:
Last Name:DIAMAL
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17307 PAGONIA DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-5932
Mailing Address - Country:US
Mailing Address - Phone:407-346-0506
Mailing Address - Fax:
Practice Address - Street 1:17307 PAGONIA DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5932
Practice Address - Country:US
Practice Address - Phone:407-346-0506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA33391172M00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist