Provider Demographics
NPI:1417404005
Name:INCINGO SOURCE MANAGEMENT
Entity Type:Organization
Organization Name:INCINGO SOURCE MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUJII
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-631-8709
Mailing Address - Street 1:112 SOUTH MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 S MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-1953
Practice Address - Country:US
Practice Address - Phone:844-631-8709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies