Healthcare Provider Details

I. General information

NPI: 1134908932
Provider Name (Legal Business Name): DIABETES TREATMENT CENTERS OF AMERICA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 E FOREMASTER DR STE 340
ST GEORGE UT
84790-4506
US

IV. Provider business mailing address

PO BOX 461338
LEEDS UT
84746-1338
US

V. Phone/Fax

Practice location:
  • Phone: 435-216-9290
  • Fax:
Mailing address:
  • Phone: 509-842-8987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ADAM LAW
Title or Position: MANAGING MEMBER
Credential:
Phone: 509-842-8987