Provider Demographics
NPI:1417102344
Name:A&L GOODSOURCE MEDICAL PRODUCTS,LLC
Entity Type:Organization
Organization Name:A&L GOODSOURCE MEDICAL PRODUCTS,LLC
Other - Org Name:HOME MEDICAL EQUIPMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:HME
Authorized Official - Phone:321-972-6906
Mailing Address - Street 1:2290 N RONALD REAGAN BLVD STE 124
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3534
Mailing Address - Country:US
Mailing Address - Phone:321-972-6906
Mailing Address - Fax:321-972-6907
Practice Address - Street 1:2290 N RONALD REAGAN BLVD STE 124
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-3534
Practice Address - Country:US
Practice Address - Phone:321-972-6906
Practice Address - Fax:321-972-6907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1313549332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6233300001Medicare NSC