Provider Demographics
NPI:1700245198
Name:DESERT DIAGNOSTIC HEALTH SERVICES
Entity Type:Organization
Organization Name:DESERT DIAGNOSTIC HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:KANCILIA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:623-335-1103
Mailing Address - Street 1:6929 N HAYDEN RD
Mailing Address - Street 2:C4 -130
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250-7978
Mailing Address - Country:US
Mailing Address - Phone:623-335-1103
Mailing Address - Fax:
Practice Address - Street 1:6929 N HAYDEN RD
Practice Address - Street 2:C4 -130
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-7978
Practice Address - Country:US
Practice Address - Phone:623-335-1103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8363111NN0400X
AZ363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty