Provider Demographics
NPI:1265502439
Name:NATIONAL MED SOURCE LLC
Entity Type:Organization
Organization Name:NATIONAL MED SOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC
Authorized Official - Prefix:MRS
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-539-4445
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:NC
Mailing Address - Zip Code:28689-0103
Mailing Address - Country:US
Mailing Address - Phone:704-539-4445
Mailing Address - Fax:
Practice Address - Street 1:1892 WEST MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:NC
Practice Address - Zip Code:28689-9049
Practice Address - Country:US
Practice Address - Phone:704-539-4445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703861Medicaid
NC7703861Medicaid