Provider Demographics
NPI:1861487191
Name:LAKE DIABETES SUPPLY, INC
Entity Type:Organization
Organization Name:LAKE DIABETES SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:HARTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-304-5941
Mailing Address - Street 1:508 N HARBOR CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-6838
Mailing Address - Country:US
Mailing Address - Phone:321-255-9800
Mailing Address - Fax:321-751-1145
Practice Address - Street 1:2555 S ATLANTIC AVE
Practice Address - Street 2:SUITE 1205
Practice Address - City:DAYTONA BEACH SHORES
Practice Address - State:FL
Practice Address - Zip Code:32118-5546
Practice Address - Country:US
Practice Address - Phone:386-304-5941
Practice Address - Fax:386-304-5941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR9283OtherBCBS IDENTIFIER