Provider Demographics
NPI:1629264429
Name:DIABETIC LIFE SUPPLY, LLC.
Entity Type:Organization
Organization Name:DIABETIC LIFE SUPPLY, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:702-880-9500
Mailing Address - Street 1:4270 S DECATUR BLVD
Mailing Address - Street 2:STE. B1-B
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-6802
Mailing Address - Country:US
Mailing Address - Phone:702-880-9500
Mailing Address - Fax:702-880-9507
Practice Address - Street 1:4270 S DECATUR BLVD
Practice Address - Street 2:STE. B1-B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-6802
Practice Address - Country:US
Practice Address - Phone:702-880-9500
Practice Address - Fax:702-880-9507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100513194Medicaid
NV6021670001Medicare NSC