=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053319137
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CERTIFIED DIABETIC SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3030 HORSESHOE DR S
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34104-6143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-430-5000
-----------------------------------------------------
Fax | 239-403-7722
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3030 HORSESHOE DR S
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34104-6139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-430-5000
-----------------------------------------------------
Fax | 239-403-7722
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. BRENT PETERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-430-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------