Healthcare Provider Details

I. General information

NPI: 1902088073
Provider Name (Legal Business Name): DIABETIC TESTING SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 10/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4204 GARDENDALE
SAN ANTONIO TX
78229-3132
US

IV. Provider business mailing address

4204 GARDENDALE SUITE 104
SAN ANTONIO TX
78229-3132
US

V. Phone/Fax

Practice location:
  • Phone: 210-593-9283
  • Fax:
Mailing address:
  • Phone: 210-593-9283
  • Fax: 210-593-9284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0055752
License Number StateTX

VIII. Authorized Official

Name: MR. RODNEY DALE GRAY
Title or Position: OWNER
Credential: RCP. CRT
Phone: 210-593-9283