1063415834 NPI number — ADVANCED DIABETIC SERVICES

Table of content: MR. PETER KITHENE WILSON (NPI 1386254951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063415834 NPI number — ADVANCED DIABETIC SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED DIABETIC SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063415834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10327
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURFREESBORO
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37129-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-896-4237
Provider Business Mailing Address Fax Number:
615-848-1026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 HERITAGE PARK DR
Provider Second Line Business Practice Location Address:
STE 403
Provider Business Practice Location Address City Name:
MURFREESBORO
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37129-0505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-896-4237
Provider Business Practice Location Address Fax Number:
615-848-1026
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SAALFELD
Authorized Official First Name:
BEN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
615-896-4237

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1158950 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1454235 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9058850 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2403063 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: XDME03007 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000649500 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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