Provider Demographics
NPI:1982765095
Name:DIABETIC SERVICES & SUPPLIES INC
Entity type:Organization
Organization Name:DIABETIC SERVICES & SUPPLIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKER
Authorized Official - Suffix:
Authorized Official - Credentials:C-PED
Authorized Official - Phone:904-230-7667
Mailing Address - Street 1:109 CARDEN PL
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7217
Mailing Address - Country:US
Mailing Address - Phone:904-230-7667
Mailing Address - Fax:866-435-9440
Practice Address - Street 1:109 CARDEN PL
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-7217
Practice Address - Country:US
Practice Address - Phone:904-230-7667
Practice Address - Fax:866-435-9440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4672010001Medicare ID - Type Unspecified