Provider Demographics
NPI:1255528741
Name:DIAGNOSTIC SLEEP AND RESPIRATORY CENTER LLC
Entity type:Organization
Organization Name:DIAGNOSTIC SLEEP AND RESPIRATORY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HACKWORTH-STOCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:CRT,RPSGT
Authorized Official - Phone:520-586-4729
Mailing Address - Street 1:282 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85602-6612
Mailing Address - Country:US
Mailing Address - Phone:520-586-4729
Mailing Address - Fax:520-423-3977
Practice Address - Street 1:282 E 4TH ST
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-6612
Practice Address - Country:US
Practice Address - Phone:520-586-4729
Practice Address - Fax:520-423-3977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA9504261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ283007Medicaid
AZ283007Medicaid