Basic Information
| Provider Information | |||||||||
| NPI: | 1275856247 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIABETIC HEALTH, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065988813 | ||||||||
| FaxNumber: | 6065980983 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 MEMORIAL DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065988813 | ||||||||
| FaxNumber: | 6065980983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2010 | ||||||||
| LastUpdateDate: | 10/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | SPADY | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6065988813 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 710016290 | 05 | KY | MEDICAID | 000000672417 | 01 | KY | ANTHEM BLUE CROSS BLUE SHIELD | OTHER |