Provider Demographics
NPI:1750480901
Name:ADVANCED DIABETIC SOLUTIONS LLC
Entity Type:Organization
Organization Name:ADVANCED DIABETIC SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:SANTULLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-339-1190
Mailing Address - Street 1:1580 ATKINSON RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5600
Mailing Address - Country:US
Mailing Address - Phone:770-339-1190
Mailing Address - Fax:770-339-1192
Practice Address - Street 1:1580 ATKINSON RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5600
Practice Address - Country:US
Practice Address - Phone:770-339-1190
Practice Address - Fax:770-339-1192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13222Z00000X
DECFM01708224900000X
DECPED2905224L00000X
DECPED1966224L00000X
MDC49737225000000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Multi-Specialty
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthistGroup - Multi-Specialty
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1366753196Medicare NSC
GA5663860001Medicare NSC
HI1558672386Medicare NSC