MEDICARE: DIABETIC RENEWAL CENTER 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	207Q00000X	Family Medicine Physician
2	207Q00000X	Family Medicine Physician	F3205	TX
3	207R00000X	Internal Medicine Physician
4	261QI0500X	Infusion Therapy Clinic/Center	261Q10500X	TX

General Provider Information

NPI Number	:	1750764189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIABETIC RENEWAL CENTER LLC

Provider Business Mailing Address
First Line	:	1015 PRUITT PL STE 105
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-1154
Country	:	US
Telephone Number	:	903-258-6000
Fax Number	:	903-526-0565

Provider Business Practice Location Address
First Line	:	1015 PRUITT PL STE 105
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-1154
Country	:	US
Telephone Number	:	903-528-6000
Fax Number	:	903-526-0565

Authorized Official
Title or Position	:	OWNER
Name	:	JEFF E DETHLEFSEN
Credential	:
Telephone Number	:	903-258-6000

Provider Enumeration Date	:	07/02/2015
Last Update Date	:	07/21/2022

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