Provider Demographics
NPI:1376596866
Name:DIABETIC SUPPLIES AND MORE, INC
Entity Type:Organization
Organization Name:DIABETIC SUPPLIES AND MORE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-649-5600
Mailing Address - Street 1:6230 MCLEOD DR
Mailing Address - Street 2:# 140
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-4049
Mailing Address - Country:US
Mailing Address - Phone:702-649-5600
Mailing Address - Fax:702-736-2199
Practice Address - Street 1:6230 MCLEOD DR
Practice Address - Street 2:# 140
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-4049
Practice Address - Country:US
Practice Address - Phone:702-649-5600
Practice Address - Fax:702-736-2199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMP00320332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505201Medicaid
CT003128099Medicaid
CT003128099Medicaid