1992966998 NPI number — DIABETES AMERICA AZ LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992966998 NPI number — DIABETES AMERICA AZ LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIABETES AMERICA AZ LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992966998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13171 MISTY WILLOW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77070-5635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-237-3500
Provider Business Mailing Address Fax Number:
832-237-0200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2875 W RAY RD
Provider Second Line Business Practice Location Address:
SUITE 16
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85224-3524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-855-6075
Provider Business Practice Location Address Fax Number:
480-855-6085
Provider Enumeration Date:
06/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
TINA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
713-840-5245

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 407282 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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