Provider Demographics
NPI:1619402799
Name:DIABETES RELIEF UTAH OGDEN LLC
Entity Type:Organization
Organization Name:DIABETES RELIEF UTAH OGDEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PCA/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-515-4100
Mailing Address - Street 1:2086 NORTH 1700 WEST
Mailing Address - Street 2:STE. D
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041
Mailing Address - Country:US
Mailing Address - Phone:385-515-4100
Mailing Address - Fax:385-351-1150
Practice Address - Street 1:2086 N 1700 W STE D
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041
Practice Address - Country:US
Practice Address - Phone:385-515-4100
Practice Address - Fax:385-351-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy