Provider Demographics
NPI:1205868072
Name:EXCELL DIABETIC SUPPLY LLC
Entity Type:Organization
Organization Name:EXCELL DIABETIC SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-351-0622
Mailing Address - Street 1:24901 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2203
Mailing Address - Country:US
Mailing Address - Phone:248-351-0622
Mailing Address - Fax:248-479-1929
Practice Address - Street 1:24901 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2203
Practice Address - Country:US
Practice Address - Phone:248-351-0622
Practice Address - Fax:248-479-1929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540F319370OtherBLUE CROSS BLUE SHEILD
MI540F319370OtherBLUE CROSS BLUE SHEILD
MI540F319370OtherBLUE CROSS BLUE SHEILD