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
StateLicense IDTaxonomies
NVNV20101840350332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies