Provider Demographics
NPI:1649747825
Name:INTERVENTIONAL DIABETES CENTER, LLC
Entity Type:Organization
Organization Name:INTERVENTIONAL DIABETES CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-594-7346
Mailing Address - Street 1:1060 E COUNTY LINE RD # 3A-288
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20735 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095-8266
Practice Address - Country:US
Practice Address - Phone:601-594-7346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-25
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center