Provider Demographics
NPI:1528465424
Name:ADVANCED DIABETES MANAGEMENT CENTER LLC
Entity type:Organization
Organization Name:ADVANCED DIABETES MANAGEMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATIVEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-842-7840
Mailing Address - Street 1:449 GLOSTER CREEK
Mailing Address - Street 2:SUITE H-9
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-0000
Mailing Address - Country:US
Mailing Address - Phone:662-842-7840
Mailing Address - Fax:662-842-7873
Practice Address - Street 1:449 GLOSTER CREEK
Practice Address - Street 2:SUITE H-9
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-0000
Practice Address - Country:US
Practice Address - Phone:662-842-7840
Practice Address - Fax:662-842-7873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR873068363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty