Provider Demographics
NPI:1104022169
Name:THE DIABETIC PLACE LLC
Entity Type:Organization
Organization Name:THE DIABETIC PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:954-990-0461
Mailing Address - Street 1:PO BOX 848182
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33084-0182
Mailing Address - Country:US
Mailing Address - Phone:954-990-0461
Mailing Address - Fax:954-990-0465
Practice Address - Street 1:10472 TAFT ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-2819
Practice Address - Country:US
Practice Address - Phone:954-990-0461
Practice Address - Fax:954-990-0465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1956772363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL281108100Medicaid
FLAF948Medicare UPIN