Healthcare Provider Details

I. General information

NPI: 1861701062
Provider Name (Legal Business Name): DIABETIC LIFE ACADEMY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4270 S. DECATUR BLVD. SUITE B-1B
LAS VEGAS NV
89103-6800
US

IV. Provider business mailing address

4270 S. DECATUR BLVD. SUITE B-1B
LAS VEGAS NV
89103-6800
US

V. Phone/Fax

Practice location:
  • Phone: 702-880-9500
  • Fax: 702-880-9507
Mailing address:
  • Phone: 702-880-9500
  • Fax: 702-880-9507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2061-0219
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number2061-0219
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number2000394-810
License Number StateNV

VIII. Authorized Official

Name: MS. BRANDY LYNN MOSLEY
Title or Position: OFFICE MANAGER/COMPLIANCE OFFICER
Credential:
Phone: 702-880-9500