Provider Demographics
NPI:1003124017
Name:COMPREHENSIVE DIABETIC SUPPLIES, LLC
Entity Type:Organization
Organization Name:COMPREHENSIVE DIABETIC SUPPLIES, LLC
Other - Org Name:COMPREHENSIVE DIABETIC & NUTRITION EDUCATION, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:QUILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-585-1540
Mailing Address - Street 1:21541 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2207
Mailing Address - Country:US
Mailing Address - Phone:586-585-1540
Mailing Address - Fax:586-585-1537
Practice Address - Street 1:21541 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2207
Practice Address - Country:US
Practice Address - Phone:586-585-1540
Practice Address - Fax:586-585-1537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6253130001Medicare NSC