Provider Demographics
NPI:1144379165
Name:TARASOURCE LLC
Entity Type:Organization
Organization Name:TARASOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-CEO
Authorized Official - Prefix:
Authorized Official - First Name:NORBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-662-4955
Mailing Address - Street 1:3690 SOUTHWESTERN BLVD
Mailing Address - Street 2:PO BOX 0428
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-662-4955
Mailing Address - Fax:716-972-0338
Practice Address - Street 1:3690 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1720
Practice Address - Country:US
Practice Address - Phone:716-662-4955
Practice Address - Fax:716-667-9230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
5439100001Medicare ID - Type Unspecified