Provider Demographics
NPI:1417317082
Name:NEBSOURCE LLC
Entity Type:Organization
Organization Name:NEBSOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-576-8918
Mailing Address - Street 1:4890 W CAMINO DE LA AMAPOLA
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745
Mailing Address - Country:US
Mailing Address - Phone:520-576-8918
Mailing Address - Fax:888-872-0212
Practice Address - Street 1:4890 W CAMINO DE LA AMAPOLA
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745
Practice Address - Country:US
Practice Address - Phone:520-576-8918
Practice Address - Fax:888-872-0212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-25
Last Update Date:2016-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2194340332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies