1336473164 NPI number — SINGLE SOURCE MEDICAL, LLC

Table of content: (NPI 1336473164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336473164 NPI number — SINGLE SOURCE MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SINGLE SOURCE MEDICAL, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336473164
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2868 PROSPECT PARK DR
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
RANCHO CORDOVA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95670-6020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-631-1236
Provider Business Mailing Address Fax Number:
916-636-9787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2868 PROSPECT PARK DR
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
RANCHO CORDOVA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95670-6020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-631-1236
Provider Business Practice Location Address Fax Number:
916-636-9787
Provider Enumeration Date:
09/26/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PETERSEN
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
916-631-1236

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)