Provider Demographics
NPI:1871759118
Name:NEIGHBORHOOD DIABETES, INC.
Entity type:Organization
Organization Name:NEIGHBORHOOD DIABETES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-398-2122
Mailing Address - Street 1:8881 S US HIGHWAY 1
Mailing Address - Street 2:ATTN: LICENSING DEPARTMENT
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3401
Mailing Address - Country:US
Mailing Address - Phone:772-398-2122
Mailing Address - Fax:844-363-4341
Practice Address - Street 1:5976 HOFFNER AVENUE
Practice Address - Street 2:SUITE 607
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-4821
Practice Address - Country:US
Practice Address - Phone:866-784-5647
Practice Address - Fax:844-363-4341
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEIGHBORHOOD HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-06
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031984800Medicaid
FL1228070003Medicare NSC