Provider Demographics
NPI:1376080309
Name:INTERNATIONAL PRE-DIABETES CENTER INC
Entity Type:Organization
Organization Name:INTERNATIONAL PRE-DIABETES CENTER INC
Other - Org Name:INTERNATIONAL PRE-DIABETES CENTER INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER (CEO)
Authorized Official - Prefix:DR
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD APP, CDE, B
Authorized Official - Phone:818-625-6756
Mailing Address - Street 1:14421 GLORIETTA DR
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-4533
Mailing Address - Country:US
Mailing Address - Phone:818-714-2066
Mailing Address - Fax:818-387-6224
Practice Address - Street 1:14500 ROSCOE BLVD., 4TH FLOOR
Practice Address - Street 2:4TH FLOOR
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402
Practice Address - Country:US
Practice Address - Phone:818-714-2066
Practice Address - Fax:818-387-6224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-29
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA163WD0400X, 174H00000X, 251V00000X, 332B00000X
CA100281835G0303X
251B00000X, 332B00000X
CA38828251S00000X, 332B00000X
CA96123332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No1835G0303XPharmacy Service ProvidersPharmacistGeriatricGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA96123OtherDIABETES HOME MEDICAL DEVICE, DEPT. OF PUBLIC HEALTH, FOOD & DRUG BRANCH
CA7658690001Medicaid
CA1376080309Medicaid
CA200913353OtherCERTIFIED DIABETES EDUCATOR