MEDICARE: LAKE DIABETES SUPPLY, INC

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		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R9283	OTHER	FL	BCBS IDENTIFIER

General Provider Information

NPI Number	:	1861487191
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE DIABETES SUPPLY, INC

Provider Business Mailing Address
First Line	:	508 N HARBOR CITY BLVD
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32935-6838
Country	:	US
Telephone Number	:	321-255-9800
Fax Number	:	321-751-1145

Provider Business Practice Location Address
First Line	:	2555 S ATLANTIC AVE
Second Line	:	SUITE 1205
City	:	DAYTONA BEACH SHORES
State	:	FL
Zip	:	32118-5546
Country	:	US
Telephone Number	:	386-304-5941
Fax Number	:	386-304-5941

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RICHARD B HARTWELL
Credential	:
Telephone Number	:	386-304-5941

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	07/21/2022

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