Provider Demographics
NPI:1184715005
Name:CLINICAL DIAGNOSTIC SERVICES, LLC
Entity type:Organization
Organization Name:CLINICAL DIAGNOSTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED MEDICAL OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BEAULIEU
Authorized Official - Suffix:
Authorized Official - Credentials:CMOM
Authorized Official - Phone:775-753-3770
Mailing Address - Street 1:845 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-3831
Mailing Address - Country:US
Mailing Address - Phone:775-753-3770
Mailing Address - Fax:505-753-3772
Practice Address - Street 1:5146 ELK HORN PEAK DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-6429
Practice Address - Country:US
Practice Address - Phone:775-753-3770
Practice Address - Fax:505-753-3772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT0090742Medicare ID - Type Unspecified