Provider Demographics
NPI:1033199666
Name:DIABETES SPECIALTY CENTER
Entity Type:Organization
Organization Name:DIABETES SPECIALTY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-263-5442
Mailing Address - Street 1:3793 SOUTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4828
Mailing Address - Country:US
Mailing Address - Phone:801-268-9699
Mailing Address - Fax:801-268-9929
Practice Address - Street 1:3744 SECOND STREET
Practice Address - Street 2:STE A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115
Practice Address - Country:US
Practice Address - Phone:801-268-9699
Practice Address - Fax:888-321-7719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5738699-1703333600000X, 3336C0003X
UT8021342-1703333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FD2709725OtherDEA
3851290001Medicare NSC