Healthcare Provider Details

I. General information

NPI: 1750480901
Provider Name (Legal Business Name): ADVANCED DIABETIC SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 ATKINSON RD
LAWRENCEVILLE GA
30043-5600
US

IV. Provider business mailing address

1580 ATKINSON RD
LAWRENCEVILLE GA
30043-5600
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-1190
  • Fax: 770-339-1192
Mailing address:
  • Phone: 770-339-1190
  • Fax: 770-339-1192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number13
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberC49737
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License NumberCFM01708
License Number StateDE
# 5
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberCPED2905
License Number StateDE
# 6
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberCPED1966
License Number StateDE

VIII. Authorized Official

Name: MR. GREGORY PETER SANTULLI
Title or Position: PRESIDENT
Credential:
Phone: 770-339-1190