Provider Demographics
NPI:1629526595
Name:AZ DIABETES EDUCATION, LLC
Entity Type:Organization
Organization Name:AZ DIABETES EDUCATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LALLY
Authorized Official - Suffix:
Authorized Official - Credentials:MS RDN CDE
Authorized Official - Phone:480-593-9348
Mailing Address - Street 1:2309 E LYNWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2229
Mailing Address - Country:US
Mailing Address - Phone:480-593-9348
Mailing Address - Fax:480-834-4405
Practice Address - Street 1:2309 E LYNWOOD ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-2229
Practice Address - Country:US
Practice Address - Phone:480-593-9348
Practice Address - Fax:480-834-4405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ68870Medicare PIN