1760491898 NPI number — DIABETIC AND MEDICAL RESOURCES CORP

Table of content: (NPI 1760491898)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760491898 NPI number — DIABETIC AND MEDICAL RESOURCES CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIABETIC AND MEDICAL RESOURCES CORP
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:
1760491898
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3999 DUTCHMANS LN
Provider Second Line Business Mailing Address:
STE. 3 F
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-376-3979
Provider Business Mailing Address Fax Number:
502-899-5209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3999 DUTCHMANS LN
Provider Second Line Business Practice Location Address:
SUITE 3 F
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-376-3979
Provider Business Practice Location Address Fax Number:
502-899-5209
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VILDER
Authorized Official First Name:
YELENA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
502-376-3979

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  051629 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50008839 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2638618000 . This is a "DME/PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000384504 . This is a "DME/BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200511350A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90011305 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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