Healthcare Provider Details

I. General information

NPI: 1841279155
Provider Name (Legal Business Name): DIABETES SPECIALTY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3793 SOUTH STATE STREET
SALT LAKE CITY UT
84115-4828
US

IV. Provider business mailing address

3793 SOUTH STATE STREET
SALT LAKE CITY UT
84115
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-9699
  • Fax: 801-268-9929
Mailing address:
  • Phone: 801-268-9699
  • Fax: 801-268-9929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4781762-0160
License Number StateUT

VIII. Authorized Official

Name: MS. KIM E DOMAN
Title or Position: CONTROLLER
Credential:
Phone: 801-263-5442