Provider Demographics
NPI:1619226487
Name:A - Z DIABETES CARE CLUB LLC
Entity Type:Organization
Organization Name:A - Z DIABETES CARE CLUB LLC
Other - Org Name:DIABETES CARE CLUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-815-3223
Mailing Address - Street 1:500 EAGLES LANDING DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-2899
Mailing Address - Country:US
Mailing Address - Phone:863-808-5691
Mailing Address - Fax:863-808-5692
Practice Address - Street 1:500 EAGLES LANDING DR
Practice Address - Street 2:SUITE B
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-2899
Practice Address - Country:US
Practice Address - Phone:863-808-5691
Practice Address - Fax:863-808-5692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4415480002Medicare NSC