MEDICARE: ADVANCED DYSPHAGIA DIAGNOSTICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1558902361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DYSPHAGIA DIAGNOSTICS LLC

Provider Business Mailing Address
First Line	:	236 S 3RD ST STE 332
Second Line	:
City	:	MONTROSE
State	:	CO
Zip	:	81401-3618
Country	:	US
Telephone Number	:	909-213-5967
Fax Number	:

Provider Business Practice Location Address
First Line	:	1465 S UTE DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2433
Country	:	US
Telephone Number	:	909-213-5967
Fax Number	:	509-356-4607

Authorized Official
Title or Position	:	OWNER
Name	:	KIMBERLY A GEMMELL
Credential	:
Telephone Number	:	909-213-5967

Provider Enumeration Date	:	10/02/2019
Last Update Date	:	10/02/2019

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Directions to “ADVANCED DYSPHAGIA DIAGNOSTICS LLC ” Practice Location

Language	Start Address	Practice Location

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