Healthcare Provider Details

I. General information

NPI: 1003901406
Provider Name (Legal Business Name): DIAMOND PT DIABETIC SUPPL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 WALKER ROAD
CAMPOBELLO SC
29322-9053
US

IV. Provider business mailing address

149 WALKER ROAD
CAMPOBELLO SC
29322-9053
US

V. Phone/Fax

Practice location:
  • Phone: 864-472-5517
  • Fax: 864-278-0650
Mailing address:
  • Phone: 864-472-5517
  • Fax: 864-278-0650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL MOORE III
Title or Position: PRESIDENT
Credential: C. PED
Phone: 864-472-5517