Provider Demographics
NPI:1760499859
Name:INTERMOUNTAIN DIABETIC SUPPLY
Entity Type:Organization
Organization Name:INTERMOUNTAIN DIABETIC SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-883-9735
Mailing Address - Street 1:2330 S MAIN ST STE 18
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2757
Mailing Address - Country:US
Mailing Address - Phone:801-883-9735
Mailing Address - Fax:801-883-9736
Practice Address - Street 1:2330 S MAIN ST STE 18
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2757
Practice Address - Country:US
Practice Address - Phone:801-883-9735
Practice Address - Fax:801-883-9736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
4860480001Medicare NSC