Provider Demographics
NPI:1093750218
Name:CERTIFIED DIABETIC SUPPLIES, INC
Entity Type:Organization
Organization Name:CERTIFIED DIABETIC SUPPLIES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LOWELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:239-430-5000
Mailing Address - Street 1:10061 AMBERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8502
Mailing Address - Country:US
Mailing Address - Phone:239-430-5000
Mailing Address - Fax:800-529-0543
Practice Address - Street 1:10061 AMBERWOOD RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8502
Practice Address - Country:US
Practice Address - Phone:239-430-5000
Practice Address - Fax:800-529-0543
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CERTIFIED DIABETIC SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-19
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF97000004927332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL951571200Medicaid
C08468131Medicare ID - Type UnspecifiedREGION D SUBMIT ID
FL0925330001Medicare NSC
FL0925330001Medicare ID - Type UnspecifiedPROVIDER ID
C08468131Medicare ID - Type UnspecifiedREGION C SUBMIT ID
FLP4488Medicare ID - Type UnspecifiedMED FL EDUCATION SUB ID
FL951571200Medicaid
C08468131Medicare ID - Type UnspecifiedREGION A SUBMIT ID
FLE8771AMedicare ID - Type UnspecifiedEDUCATION MEDICARE PROV