Provider Demographics
NPI:1053818963
Name:DEFY DIABETES, LLC
Entity type:Organization
Organization Name:DEFY DIABETES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:LEHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDE
Authorized Official - Phone:623-500-6207
Mailing Address - Street 1:18301 N 79TH AVE STE C136
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8471
Mailing Address - Country:US
Mailing Address - Phone:623-500-6207
Mailing Address - Fax:
Practice Address - Street 1:18301 N 79TH AVE STE C136
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8471
Practice Address - Country:US
Practice Address - Phone:623-500-6207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-07
Last Update Date:2018-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ926214133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1609845916Medicaid