Provider Demographics
NPI:1437196367
Name:SOURCE ONE MOBILITY, INC
Entity Type:Organization
Organization Name:SOURCE ONE MOBILITY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:KLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-463-5590
Mailing Address - Street 1:629 PHOENIX DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7392
Mailing Address - Country:US
Mailing Address - Phone:757-463-5590
Mailing Address - Fax:757-463-5592
Practice Address - Street 1:629 PHOENIX DR
Practice Address - Street 2:SUITE 115
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7392
Practice Address - Country:US
Practice Address - Phone:757-463-5590
Practice Address - Fax:757-463-5592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA838765200332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9108432Medicaid
VA9108432Medicaid