1770575706 NPI number — AMERICAN DIABETIC SUPPLY, INC.

Table of content: (NPI 1770575706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770575706 NPI number — AMERICAN DIABETIC SUPPLY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERICAN DIABETIC 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:
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:
1770575706
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:
PO BOX 602
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48376-0602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-449-8055
Provider Business Mailing Address Fax Number:
888-449-8057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28317 BECK RD
Provider Second Line Business Practice Location Address:
E-18
Provider Business Practice Location Address City Name:
WIXOM
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48393-4729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-449-8055
Provider Business Practice Location Address Fax Number:
888-449-8057
Provider Enumeration Date:
08/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CARLIN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-449-8055

Provider Taxonomy Codes

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

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

  • Identifier: 2750287 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 54-0-F3-1442-0 . This is a "BCBSMI PROVIDER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4979367 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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