Provider Demographics
NPI:1245484906
Name:DIABETES SPECIALTY CENTER LLC
Entity type:Organization
Organization Name:DIABETES SPECIALTY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-743-2800
Mailing Address - Street 1:3793 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4828
Mailing Address - Country:US
Mailing Address - Phone:801-392-2362
Mailing Address - Fax:801-392-5643
Practice Address - Street 1:1254 N STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6432
Practice Address - Country:US
Practice Address - Phone:801-392-2362
Practice Address - Fax:801-392-5643
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIABETES SPECIALTY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-07
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5386155Medicaid
UT1841279155OtherMEDICARE NPI
UT5386155Medicaid