Provider Demographics
NPI:1114117488
Name:DIABETES CENTER LLC
Entity Type:Organization
Organization Name:DIABETES CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:NICOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-353-0288
Mailing Address - Street 1:PO BOX 15010
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29587-5010
Mailing Address - Country:US
Mailing Address - Phone:843-353-0288
Mailing Address - Fax:843-257-9770
Practice Address - Street 1:11891 PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576
Practice Address - Country:US
Practice Address - Phone:843-353-0288
Practice Address - Fax:843-357-9770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30634207Q00000X
SC14684207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCB964666957Medicare UPIN