Organization
LAKE DIABETES SUPPLY, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RICHARD B HARTWELL (PRESIDENT)
(386) 304-5941
Entity
Organization
Contact information
Practice address
2555 S ATLANTIC AVE, SUITE 1205, DAYTONA BEACH SHORES, FL 32118-5546
(386) 304-5941
(386) 304-5941
Mailing address
508 N HARBOR CITY BLVD, MELBOURNE, FL 32935-6838
(321) 255-9800
(321) 751-1145
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
R9283
BCBS IDENTIFIER
FL
Enumeration date
09/13/2005
Last updated
07/21/2022
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