Provider Demographics
NPI:1861701062
Name:DIABETIC LIFE ACADEMY, LLC
Entity type:Organization
Organization Name:DIABETIC LIFE ACADEMY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/COMPLIANCE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MOSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-880-9500
Mailing Address - Street 1:4270 S. DECATUR BLVD.
Mailing Address - Street 2:SUITE B-1B
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-6800
Mailing Address - Country:US
Mailing Address - Phone:702-880-9500
Mailing Address - Fax:702-880-9507
Practice Address - Street 1:4270 S. DECATUR BLVD.
Practice Address - Street 2:SUITE B-1B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-6800
Practice Address - Country:US
Practice Address - Phone:702-880-9500
Practice Address - Fax:702-880-9507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2061-0219133V00000X, 305S00000X
NV2000394-810332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No305S00000XManaged Care OrganizationsPoint of Service