Provider Demographics
NPI:1366866246
Name:HEALTHSOURCE MEDICAL NETWORK, INC.
Entity Type:Organization
Organization Name:HEALTHSOURCE MEDICAL NETWORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARNOLD
Authorized Official - Middle Name:
Authorized Official - Last Name:SANVICENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-971-9334
Mailing Address - Street 1:417 W ALLEN AVE STE 18
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4709
Mailing Address - Country:US
Mailing Address - Phone:909-971-9334
Mailing Address - Fax:909-575-3573
Practice Address - Street 1:11190 WARNER AVE STE 302
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4047
Practice Address - Country:US
Practice Address - Phone:714-241-8000
Practice Address - Fax:714-241-8003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty