Provider Demographics
NPI:1073554911
Name:AMBASSADOR DIABETIC SUPPLIES AND SERVICES, LLC
Entity type:Organization
Organization Name:AMBASSADOR DIABETIC SUPPLIES AND SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:803-794-4545
Mailing Address - Street 1:1220 KNOX ABBOTT DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-3350
Mailing Address - Country:US
Mailing Address - Phone:803-794-4545
Mailing Address - Fax:803-794-4522
Practice Address - Street 1:1220 KNOX ABBOTT DR
Practice Address - Street 2:SUITE F
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-3350
Practice Address - Country:US
Practice Address - Phone:803-794-4545
Practice Address - Fax:803-794-4522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2530Medicaid
OH2628811Medicaid
=========OtherEIN
SC5427990001Medicare ID - Type Unspecified