Main Street Diagnostic LLC

Primary specialty

Psychiatric HospitalTaxonomy code 283Q00000X

License

BH-2492 Issued in AZ

Legal business name

MAIN STREET DIAGNOSTIC LLC

Practice address

636 N Main St
Cottonwood, AZ 86326-3725

Phone

(928) 639-4440

Fax

(928) 639-3924

NPI assigned

Oct 20, 2005

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Maria Carrillo

Title

Finance Coordinator

Phone

(928) 639-4440

Specialties & licenses 1

Addresses

Other identifiers 7

Other names 1

• Mingus Center (Level 1 Sub Acute Agency) Doing business as

Tax ID family

Main Street Diagnostic LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Main Street Diagnostic, LLC

  • Substance Abuse Rehabilitation Facility
  • Cottonwood, AZ
  • NPI 1972639748
  NPD tax ID

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1129766400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1225027477",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "636 N MAIN ST",
            "city": "COTTONWOOD",
            "state": "AZ",
            "postal_code": "863263725",
            "telephone_number": "928-639-4440",
            "fax_number": "928-639-3924"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "636 N MAIN ST",
            "city": "COTTONWOOD",
            "state": "AZ",
            "postal_code": "863263725",
            "telephone_number": "928-639-4440",
            "fax_number": "928-639-3924"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAIN STREET DIAGNOSTIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-20",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "CARRILLO",
        "authorized_official_first_name": "MARIA",
        "authorized_official_title_or_position": "FINANCE COORDINATOR",
        "authorized_official_telephone_number": "928-639-4440"
    },
    "taxonomies": [
        {
            "code": "283Q00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Hospital",
            "state": "AZ",
            "license": "BH-2492",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "3955228",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "JCAHCO",
            "identifier": "404204",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS PROV REG. #",
            "identifier": "AZ0209640",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ADHS LICENSE L1 SUB ACUTE",
            "identifier": "BH-2492",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CIGNA PROV REG #",
            "identifier": "2215360",
            "state": "AZ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "887317",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CENPATICO - ADULTS",
            "identifier": "100322",
            "state": "AS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mingus Center (Level 1 Sub Acute Agency)",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Todd M Lyonnais, P.T.
• Michael Joseph Maccaro, D.M.D.
• Orrin Lee Mackey, DMD
• Suzanne Maestas
• Maggie'S Home Health, LLC
• Main Street Diagnostic, LLC
• Malcolm Wilkinson, MD
• Ursula E. Mann, L.C.S.W.
• Jeffery Clark Manning, PHARMD
• Cynthia Earhart Martin, MD

• All providers in Cottonwood, AZ
• Psychiatric Hospital in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.