Provider Demographics
NPI:1558716662
Name:DIDC INC
Entity Type:Organization
Organization Name:DIDC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:VALENTIN
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-273-6658
Mailing Address - Street 1:535 S DECATUR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-3910
Mailing Address - Country:US
Mailing Address - Phone:702-562-2273
Mailing Address - Fax:702-227-8351
Practice Address - Street 1:535 S DECATUR BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-3910
Practice Address - Country:US
Practice Address - Phone:702-562-2273
Practice Address - Fax:702-227-8351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20021448940253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV=========Medicaid