Provider Demographics
NPI:1225027477
Name:MAIN STREET DIAGNOSTIC LLC
Entity Type:Organization
Organization Name:MAIN STREET DIAGNOSTIC LLC
Other - Org Name:MINGUS CENTER (LEVEL 1 SUB ACUTE AGENCY)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-639-4440
Mailing Address - Street 1:636 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-3725
Mailing Address - Country:US
Mailing Address - Phone:928-639-4440
Mailing Address - Fax:928-639-3924
Practice Address - Street 1:636 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3725
Practice Address - Country:US
Practice Address - Phone:928-639-4440
Practice Address - Fax:928-639-3924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2492283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3955228OtherAETNA
AZ404204OtherJCAHCO
AZAZ0209640OtherBCBS PROV REG. #
AZBH-2492OtherADHS LICENSE L1 SUB ACUTE
AZ2215360OtherCIGNA PROV REG #
AZ887317Medicaid
AS100322OtherCENPATICO - ADULTS
AZBH-2492OtherADHS LICENSE L1 SUB ACUTE