Provider Demographics
NPI:1740480482
Name:INNOVATIVE DIABETES SUPPLY, LLC
Entity type:Organization
Organization Name:INNOVATIVE DIABETES SUPPLY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PAZOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-289-7345
Mailing Address - Street 1:358 WALTER RD
Mailing Address - Street 2:
Mailing Address - City:RIVER RIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70123-3225
Mailing Address - Country:US
Mailing Address - Phone:504-289-7345
Mailing Address - Fax:504-667-3350
Practice Address - Street 1:824 ELMWOOD PARK BLVD STE 155
Practice Address - Street 2:
Practice Address - City:HARAHAN
Practice Address - State:LA
Practice Address - Zip Code:70123-3322
Practice Address - Country:US
Practice Address - Phone:504-708-5848
Practice Address - Fax:504-708-5846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16193382332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1023418Medicaid
6012620001Medicare NSC