Provider Demographics
NPI:1437305059
Name:MBA DIABETIC FOOTWEAR SOLUTIONS
Entity Type:Organization
Organization Name:MBA DIABETIC FOOTWEAR SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:SYNTEL
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-352-8031
Mailing Address - Street 1:7505 WATERS AVE
Mailing Address - Street 2:STE E-4
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3825
Mailing Address - Country:US
Mailing Address - Phone:912-352-8031
Mailing Address - Fax:
Practice Address - Street 1:4395 OGEECHEE RD
Practice Address - Street 2:STE 209
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-1249
Practice Address - Country:US
Practice Address - Phone:912-335-8934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
GA1071579335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE3140Medicaid
GA079591530AMedicaid
GA079591530BMedicaid
SCDE3140Medicaid