MEDICARE: A - Z DIABETES CARE CLUB 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	:	1619226487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A - Z DIABETES CARE CLUB LLC

Provider Business Mailing Address
First Line	:	500 EAGLES LANDING DR
Second Line	:	SUITE B
City	:	LAKELAND
State	:	FL
Zip	:	33810-2899
Country	:	US
Telephone Number	:	863-808-5691
Fax Number	:	863-808-5692

Provider Business Practice Location Address
First Line	:	500 EAGLES LANDING DR
Second Line	:	SUITE B
City	:	LAKELAND
State	:	FL
Zip	:	33810-2899
Country	:	US
Telephone Number	:	863-808-5691
Fax Number	:	863-808-5692

Authorized Official
Title or Position	:	SECRETARY
Name	:	MRS. JENNIFER C. PETERS
Credential	:
Telephone Number	:	615-815-3223

Provider Enumeration Date	:	09/07/2012
Last Update Date	:	09/24/2013

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