Provider Demographics
NPI:1093924730
Name:SOURCE ONE MOBILITY LLC
Entity Type:Organization
Organization Name:SOURCE ONE MOBILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-281-4500
Mailing Address - Street 1:4455 S 700 E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3153
Mailing Address - Country:US
Mailing Address - Phone:801-281-4500
Mailing Address - Fax:
Practice Address - Street 1:4455 S 700 E
Practice Address - Street 2:SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3153
Practice Address - Country:US
Practice Address - Phone:801-281-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5596831-1714332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4530290001Medicare ID - Type Unspecified