Provider Demographics
NPI:1972639748
Name:MAIN STREET DIAGNOSTIC, LLC
Entity type:Organization
Organization Name:MAIN STREET DIAGNOSTIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-639-4440
Mailing Address - Street 1:636 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-3725
Mailing Address - Country:US
Mailing Address - Phone:928-639-4440
Mailing Address - Fax:928-639-3924
Practice Address - Street 1:636 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3725
Practice Address - Country:US
Practice Address - Phone:928-639-4440
Practice Address - Fax:928-639-3924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPENDING324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility