Provider Demographics
NPI: | 1841596129 |
---|---|
Name: | IDEAL DIABETIC SUPPLIES LLC |
Entity Type: | Organization |
Organization Name: | IDEAL DIABETIC SUPPLIES LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MANAGER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | ROBERT |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BROKAW |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 702-443-5878 |
Mailing Address - Street 1: | 3031 SCENIC VALLEY WAY |
Mailing Address - Street 2: | |
Mailing Address - City: | HENDERSON |
Mailing Address - State: | NV |
Mailing Address - Zip Code: | 89052-3092 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 702-443-5878 |
Mailing Address - Fax: | 888-591-9874 |
Practice Address - Street 1: | 3031 SCENIC VALLEY WAY |
Practice Address - Street 2: | |
Practice Address - City: | HENDERSON |
Practice Address - State: | NV |
Practice Address - Zip Code: | 89052-3092 |
Practice Address - Country: | US |
Practice Address - Phone: | 702-443-5878 |
Practice Address - Fax: | 888-591-9874 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-02-02 |
Last Update Date: | 2011-02-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NV | NV20101840350 | 332B00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |