1497785182 NPI number — COMPREHENSIVE DIABETIC SOLUTIONS

Table of content: (NPI 1497785182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497785182 NPI number — COMPREHENSIVE DIABETIC SOLUTIONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE DIABETIC SOLUTIONS
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:
1497785182
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3251 POPLAR AVE
Provider Second Line Business Mailing Address:
SUITE 23
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38111-3609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-327-9440
Provider Business Mailing Address Fax Number:
901-452-6081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3251 POPLAR AVE
Provider Second Line Business Practice Location Address:
SUITE 23
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38111-3609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-327-9440
Provider Business Practice Location Address Fax Number:
901-452-6081
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCKINZIE
Authorized Official First Name:
BETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
901-327-9440

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0000000868 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000004446 . This is a "PHARMACY" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1455061 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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