Provider Demographics
NPI:1508958901
Name:DIABETES SELF MANAGEMENT SUPPLIES
Entity Type:Organization
Organization Name:DIABETES SELF MANAGEMENT SUPPLIES
Other - Org Name:DIABETES & NUTRITION CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FONDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-515-0848
Mailing Address - Street 1:12230 W FOREST HILL BLVD
Mailing Address - Street 2:SUITE 178
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-5700
Mailing Address - Country:US
Mailing Address - Phone:561-515-0848
Mailing Address - Fax:561-333-2640
Practice Address - Street 1:12230 W FOREST HILL BLVD
Practice Address - Street 2:SUITE 178
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-5700
Practice Address - Country:US
Practice Address - Phone:561-515-0848
Practice Address - Fax:561-333-2640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5233500002Medicare NSC