Provider Demographics
NPI:1053452912
Name:DIABETES EXPRESS SUPPLY CO
Entity Type:Organization
Organization Name:DIABETES EXPRESS SUPPLY CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENDRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:EBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-925-2232
Mailing Address - Street 1:4560 NORTH BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-4043
Mailing Address - Country:US
Mailing Address - Phone:225-925-2232
Mailing Address - Fax:225-926-4713
Practice Address - Street 1:4560 NORTH BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-4043
Practice Address - Country:US
Practice Address - Phone:225-925-2232
Practice Address - Fax:225-926-4713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1478750Medicaid
LA1478750Medicaid