Provider Demographics
NPI:1235858119
Name:ONE SOURCE MEDICAL & REGENERATIVE SERVICES LLC
Entity Type:Organization
Organization Name:ONE SOURCE MEDICAL & REGENERATIVE SERVICES LLC
Other - Org Name:ONE SOURCE MEDICAL & REGENERATIVE SERVICES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/MD
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-784-2903
Mailing Address - Street 1:412 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-8032
Mailing Address - Country:US
Mailing Address - Phone:915-929-9904
Mailing Address - Fax:
Practice Address - Street 1:8313 SOUTHWEST FWY STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1608
Practice Address - Country:US
Practice Address - Phone:713-784-2903
Practice Address - Fax:713-784-2908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-24
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113251608Medicaid
TX3911240Medicaid