Provider Demographics
NPI:1619045317
Name:HOME CARE DIABETES MEDICAL SUPPLY
Entity Type:Organization
Organization Name:HOME CARE DIABETES MEDICAL SUPPLY
Other - Org Name:HOME CARE DIABETES SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CHENAULT
Authorized Official - Suffix:
Authorized Official - Credentials:NONE
Authorized Official - Phone:618-277-1628
Mailing Address - Street 1:PO BOX 8429
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62222-8429
Mailing Address - Country:US
Mailing Address - Phone:618-277-1628
Mailing Address - Fax:618-277-2826
Practice Address - Street 1:1707 10TH FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-4866
Practice Address - Country:US
Practice Address - Phone:618-277-1628
Practice Address - Fax:618-277-2856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6222201Medicaid
1159210001Medicare NSC
1619045317Medicare NSC