Basic Information
| Provider Information | |||||||||
| NPI: | 1053344093 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIABETES SELF-MANAGEMENT CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 51266 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705051266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331307 | ||||||||
| FaxNumber: | 3372335764 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 W PINHOOK RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372321717 | ||||||||
| FaxNumber: | 3372321767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 11/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | NOVEMBER | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3372331307 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | C8672 | 01 | LA | BLUE CROSS BLUE SHIELD OF | OTHER |