1821078577 NPI number — MEDI-SOURCE EQUIPMENT & SUPPLY INC

Table of content: (NPI 1821078577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821078577 NPI number — MEDI-SOURCE EQUIPMENT & SUPPLY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDI-SOURCE EQUIPMENT & SUPPLY INC
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:
1821078577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 712
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YUCCA VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92286-0712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-365-6389
Provider Business Mailing Address Fax Number:
760-365-7016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57725 TWENTYNINE PALMS HWY
Provider Second Line Business Practice Location Address:
SUITE 402
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284-3046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-365-6389
Provider Business Practice Location Address Fax Number:
760-365-7016
Provider Enumeration Date:
01/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLMAN
Authorized Official First Name:
ESTA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
760-365-6389

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  53366 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DME02109F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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