Provider Demographics
NPI:1235122508
Name:PAND L DIVERSE SERVICE CORP
Entity Type:Organization
Organization Name:PAND L DIVERSE SERVICE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:BARRETO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-443-8098
Mailing Address - Street 1:2837 CORAL WAY
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3203
Mailing Address - Country:US
Mailing Address - Phone:305-443-8098
Mailing Address - Fax:305-448-7586
Practice Address - Street 1:2837 CORAL WAY
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33145-3203
Practice Address - Country:US
Practice Address - Phone:305-443-8098
Practice Address - Fax:305-448-7586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL950689000Medicaid
FL202341OtherANERIGROUP
FL950689000Medicaid