Provider Demographics
NPI:1366436107
Name:A1 DIABETES & MEDICAL SUPPLY, INC.
Entity type:Organization
Organization Name:A1 DIABETES & MEDICAL SUPPLY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:HENNESSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-255-9800
Mailing Address - Street 1:2092 SARNO RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3077
Mailing Address - Country:US
Mailing Address - Phone:321-255-9800
Mailing Address - Fax:321-751-1145
Practice Address - Street 1:636 S BAY ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-4860
Practice Address - Country:US
Practice Address - Phone:352-589-1177
Practice Address - Fax:352-589-0629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR6834OtherBCBS IDENTIFIER
FL0195730001Medicare ID - Type Unspecified