=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205125663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIABETIC DME SUPPLIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2011
-----------------------------------------------------
Last Update Date | 01/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 WHITE RD
-----------------------------------------------------
City | SHELBYVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40065-7954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-437-0523
-----------------------------------------------------
Fax | 502-220-4018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 WHITE RD
-----------------------------------------------------
City | SHELBYVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40065-7954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-437-0523
-----------------------------------------------------
Fax | 502-220-4018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL ROBERTS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-472-7948
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------