Provider Demographics
NPI:1689621393
Name:LIFE CARE DIABETIC SUPPLIES, INC.
Entity Type:Organization
Organization Name:LIFE CARE DIABETIC SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BIBY
Authorized Official - Middle Name:DAVILA
Authorized Official - Last Name:JACOBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-745-7338
Mailing Address - Street 1:PO BOX 641
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33468-0641
Mailing Address - Country:US
Mailing Address - Phone:561-745-7338
Mailing Address - Fax:561-427-6427
Practice Address - Street 1:840 JUPITER PARK DR
Practice Address - Street 2:SUITE 101
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-8947
Practice Address - Country:US
Practice Address - Phone:561-745-7335
Practice Address - Fax:561-427-6427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1312919332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA567602Medicaid
GA000326697CMedicaid
KY90011446Medicaid
TX143776601Medicaid
KS200304520AMedicaid
OK200008430AMedicaid
AL9982460Medicaid
NM7821760Medicaid
ID845265155Medicaid
FL1312919OtherHME LICENSE
LA1469017Medicaid
FL031242800Medicaid
MD401094900Medicaid
MI443086700Medicaid
AL9982460Medicaid
FL031242800Medicaid
IL=========001Medicaid
NM7821760Medicaid
NE=========54Medicaid
FL031242800Medicaid