Healthcare Provider Details

I. General information

NPI: 1700245198
Provider Name (Legal Business Name): DESERT DIAGNOSTIC HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6929 N HAYDEN RD C4 -130
SCOTTSDALE AZ
85250-7978
US

IV. Provider business mailing address

6929 N HAYDEN RD C4 -130
SCOTTSDALE AZ
85250-7978
US

V. Phone/Fax

Practice location:
  • Phone: 623-335-1103
  • Fax:
Mailing address:
  • Phone: 623-335-1103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number8363
License Number StateAZ

VIII. Authorized Official

Name: DR. DIRK KANCILIA
Title or Position: DIRECTOR
Credential: DC
Phone: 623-335-1103