Provider Demographics
NPI:1336473164
Name:SINGLE SOURCE MEDICAL, LLC
Entity Type:Organization
Organization Name:SINGLE SOURCE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-631-1236
Mailing Address - Street 1:2868 PROSPECT PARK DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-6020
Mailing Address - Country:US
Mailing Address - Phone:916-631-1236
Mailing Address - Fax:916-636-9787
Practice Address - Street 1:2868 PROSPECT PARK DR
Practice Address - Street 2:SUITE 600
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-6020
Practice Address - Country:US
Practice Address - Phone:916-631-1236
Practice Address - Fax:916-636-9787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-26
Last Update Date:2009-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies