Provider Demographics
NPI:1487905261
Name:PINNACLE DIABETES MANAGEMENT LLC
Entity type:Organization
Organization Name:PINNACLE DIABETES MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:KOTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CDE
Authorized Official - Phone:410-409-6992
Mailing Address - Street 1:867 E LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4510
Mailing Address - Country:US
Mailing Address - Phone:410-409-6992
Mailing Address - Fax:866-538-6990
Practice Address - Street 1:867 E LOMBARD ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-4510
Practice Address - Country:US
Practice Address - Phone:410-409-6992
Practice Address - Fax:866-538-6990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX2666133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty