Basic Information
| Provider Information | |||||||||
| NPI: | 1558902361 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED DYSPHAGIA DIAGNOSTICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 236 S 3RD ST STE 332 | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092135967 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1465 S UTE DR | ||||||||
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| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841082433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092135967 | ||||||||
| FaxNumber: | 5093564607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2019 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | GEMMELL | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9092135967 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVANCED DYSPHAGIA DIAGNOSTICS LLC | ||||||||
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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.