Provider Demographics
NPI:1194181206
Name:ADVANCED DYSPHAGIA DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:ADVANCED DYSPHAGIA DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GEMMELL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:909-213-5967
Mailing Address - Street 1:2233 E MAIN ST
Mailing Address - Street 2:BUSINESS OPTIONS MEDICAL BILLING
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3831
Mailing Address - Country:US
Mailing Address - Phone:970-765-0818
Mailing Address - Fax:970-497-8410
Practice Address - Street 1:611 E STAR CT
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-6704
Practice Address - Country:US
Practice Address - Phone:909-213-5967
Practice Address - Fax:509-356-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0000229235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODW7861OtherRAILROAD WORKERS MEDICARE GROUP PTAN
CO501212Medicare PIN