Provider Demographics
NPI:1568763696
Name:LAKE DIABETES SUPPLY, INC
Entity Type:Organization
Organization Name:LAKE DIABETES SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:HENNESSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-255-9800
Mailing Address - Street 1:508 N HARBOR CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-6838
Mailing Address - Country:US
Mailing Address - Phone:321-255-9800
Mailing Address - Fax:321-751-1145
Practice Address - Street 1:508 N HARBOR CITY BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6838
Practice Address - Country:US
Practice Address - Phone:321-255-9800
Practice Address - Fax:321-751-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty