MEDICARE: DIATIC MEDICAL SUPPLY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1215161625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIATIC MEDICAL SUPPLY, LLC

Provider Business Mailing Address
First Line	:	1857 WASHINGTON BLVD
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-4160
Country	:	US
Telephone Number	:	248-210-5937
Fax Number	:

Provider Business Practice Location Address
First Line	:	1857 WASHINGTON BLVD
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-4160
Country	:	US
Telephone Number	:	248-210-5937
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KEVIN DENHOLM
Credential	:
Telephone Number	:	248-210-5937

Provider Enumeration Date	:	05/13/2009
Last Update Date	:	05/24/2010

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