Provider Demographics
NPI:1841279155
Name:DIABETES SPECIALTY CENTER LLC
Entity type:Organization
Organization Name:DIABETES SPECIALTY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-263-5442
Mailing Address - Street 1:3793 SOUTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115
Mailing Address - Country:US
Mailing Address - Phone:801-268-9699
Mailing Address - Fax:801-268-9929
Practice Address - Street 1:3793 SOUTH STATE STREET
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-4828
Practice Address - Country:US
Practice Address - Phone:801-268-9699
Practice Address - Fax:801-268-9929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4781762-0160332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT184127915501Medicaid
UT184127915501Medicaid
3851290001Medicare NSC
UT=========005Medicaid