1740480482 NPI number — INNOVATIVE DIABETES SUPPLY, LLC

Table of content: (NPI 1740480482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740480482 NPI number — INNOVATIVE DIABETES SUPPLY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE DIABETES SUPPLY, LLC
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:
1740480482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
358 WALTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVER RIDGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70123-3225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-289-7345
Provider Business Mailing Address Fax Number:
504-667-3350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
824 ELMWOOD PARK BLVD STE 155
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARAHAN
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70123-3322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-708-5848
Provider Business Practice Location Address Fax Number:
504-708-5846
Provider Enumeration Date:
07/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAZOS
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
504-289-7345

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  16193382 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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