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General NPI Number Information
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NPI Number | 1003101296
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Entity Type | Organization
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Legal Business Name | 101 DIABETIC SUPPLIES, LLC
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Dates
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Enumeration Date | 06/15/2011
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Last Update Date | 08/23/2013
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Provider Practice Location Address
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Address Line | 1400 WHITE DR STE B
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City | TITUSVILLE
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State | FL
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Zip | 32780-9657
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Country | US
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Telephone | 321-676-8989
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Fax |
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Provider Business Mailing Address
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Address Line | 1400 WHITE DR STE B
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City | TITUSVILLE
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State | FL
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Zip | 32780-9657
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Country | US
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Telephone | 321-676-8989
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. DALE GREYSLAK
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Credential |
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Telephone | 321-267-7576
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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