1619045317 NPI number — HOME CARE DIABETES MEDICAL SUPPLY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619045317 NPI number — HOME CARE DIABETES MEDICAL SUPPLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOME CARE DIABETES MEDICAL SUPPLY
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:
1619045317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8429
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62222-8429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-277-1628
Provider Business Mailing Address Fax Number:
618-277-2826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1707 10TH FAIRWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62220-4866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-277-1628
Provider Business Practice Location Address Fax Number:
618-277-2856
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHENAULT
Authorized Official First Name:
ROSE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
618-277-1628

Provider Taxonomy Codes

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

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





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