Provider Demographics
NPI:1760491898
Name:DIABETIC AND MEDICAL RESOURCES CORP
Entity Type:Organization
Organization Name:DIABETIC AND MEDICAL RESOURCES CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-376-3979
Mailing Address - Street 1:3999 DUTCHMANS LN
Mailing Address - Street 2:STE. 3 F
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207
Mailing Address - Country:US
Mailing Address - Phone:502-376-3979
Mailing Address - Fax:502-899-5209
Practice Address - Street 1:3999 DUTCHMANS LN
Practice Address - Street 2:SUITE 3 F
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4714
Practice Address - Country:US
Practice Address - Phone:502-376-3979
Practice Address - Fax:502-899-5209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY051629332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50008839Medicaid
KY2638618000OtherDME/PASSPORT ADVANTAGE
KY000000384504OtherDME/BCBS
IN200511350AMedicaid
KY90011305Medicaid
KY90011305Medicaid