Provider Demographics
NPI:1043738586
Name:DIABETES RELIEF CENTER OF BRONX MSO LLC
Entity Type:Organization
Organization Name:DIABETES RELIEF CENTER OF BRONX MSO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DEANE'
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-571-9041
Mailing Address - Street 1:4441 AUBURN BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-4139
Mailing Address - Country:US
Mailing Address - Phone:916-550-1050
Mailing Address - Fax:916-550-1238
Practice Address - Street 1:2825 3RD AVE STE 200
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4066
Practice Address - Country:US
Practice Address - Phone:916-550-1050
Practice Address - Fax:916-550-1238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty