MEDICARE: DIABETIC LIFE ACADEMY, 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	133V00000X	Registered Dietitian	2061-0219	NV
2	305S00000X	Point of Service	2061-0219	NV
3	332B00000X	Durable Medical Equipment & Medical Supplies	2000394-810	NV

General Provider Information

NPI Number	:	1861701062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIABETIC LIFE ACADEMY, LLC

Provider Business Mailing Address
First Line	:	4270 S. DECATUR BLVD.
Second Line	:	SUITE B-1B
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-6800
Country	:	US
Telephone Number	:	702-880-9500
Fax Number	:	702-880-9507

Provider Business Practice Location Address
First Line	:	4270 S. DECATUR BLVD.
Second Line	:	SUITE B-1B
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-6800
Country	:	US
Telephone Number	:	702-880-9500
Fax Number	:	702-880-9507

Authorized Official
Title or Position	:	OFFICE MANAGER/COMPLIANCE OFFICER
Name	:	MS. BRANDY LYNN MOSLEY
Credential	:
Telephone Number	:	702-880-9500

Provider Enumeration Date	:	10/05/2010
Last Update Date	:	01/14/2011

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