Basic Information
| Provider Information | |||||||||
| NPI: | 1457005670 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED DYSPHAGIA DIAGNOSTICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2233 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707650804 | ||||||||
| FaxNumber: | 9704978410 | ||||||||
| Practice Location | |||||||||
| Address1: | 3045 AEROTECH PKWY UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814016305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092135967 | ||||||||
| FaxNumber: | 5093564607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2022 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | GEMMELL | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9092135967 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | SLP | ||||||||
| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.