MEDICARE: INTERMOUNTAIN DIABETIC SUPPLY

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	:	1760499859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERMOUNTAIN DIABETIC SUPPLY

Provider Business Mailing Address
First Line	:	2330 S MAIN ST STE 18
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-2757
Country	:	US
Telephone Number	:	801-883-9735
Fax Number	:	801-883-9736

Provider Business Practice Location Address
First Line	:	2330 S MAIN ST STE 18
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-2757
Country	:	US
Telephone Number	:	801-883-9735
Fax Number	:	801-883-9736

Authorized Official
Title or Position	:	OWNER
Name	:	WILLIAM GILES
Credential	:
Telephone Number	:	801-883-9735

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	04/20/2008

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