Provider Demographics
NPI:1649649021
Name:DIABETES AND LIFESTYLE MANAGEMENT, LLC
Entity type:Organization
Organization Name:DIABETES AND LIFESTYLE MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MERVILLE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:APRN
Authorized Official - Phone:603-552-3309
Mailing Address - Street 1:15 TSIENNETO RD STE 200
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-1557
Mailing Address - Country:US
Mailing Address - Phone:603-552-3309
Mailing Address - Fax:
Practice Address - Street 1:15 TSIENNETO RD STE 200
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-1557
Practice Address - Country:US
Practice Address - Phone:603-552-3309
Practice Address - Fax:603-965-4177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
NH041658-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHNP388901Medicare PIN
NHP66455Medicare UPIN