1366436107 NPI number — A1 DIABETES & MEDICAL SUPPLY, INC.

Table of content: (NPI 1366436107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366436107 NPI number — A1 DIABETES & MEDICAL SUPPLY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A1 DIABETES & MEDICAL SUPPLY, INC.
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:
6
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:
1366436107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2092 SARNO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32935-3077
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-255-9800
Provider Business Mailing Address Fax Number:
321-751-1145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
636 S BAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUSTIS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32726-4860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-589-1177
Provider Business Practice Location Address Fax Number:
352-589-0629
Provider Enumeration Date:
09/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HENNESSY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
321-255-9800

Provider Taxonomy Codes

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

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

  • Identifier: R6834 . This is a "BCBS IDENTIFIER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com