Provider Demographics
NPI:1154579746
Name:DIABETES MANAGEMENT SERVICES, LLC
Entity type:Organization
Organization Name:DIABETES MANAGEMENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:TIGUE
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:845-598-7204
Mailing Address - Street 1:700-76 BROADWAY #344
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-1674
Mailing Address - Country:US
Mailing Address - Phone:845-598-7204
Mailing Address - Fax:845-201-8319
Practice Address - Street 1:261 OLD HOOK RD
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-3102
Practice Address - Country:US
Practice Address - Phone:845-598-7204
Practice Address - Fax:845-201-8319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NJ26NC07813500163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY569991OtherPTAN
NJ127863OtherPTAN