Provider Demographics
NPI:1578224218
Name:ORTHOSOURCE, INC.
Entity Type:Organization
Organization Name:ORTHOSOURCE, INC.
Other - Org Name:KIMLOR MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HAL
Authorized Official - Last Name:DEJARNATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-373-2510
Mailing Address - Street 1:PO BOX 7510
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72766-7510
Mailing Address - Country:US
Mailing Address - Phone:479-872-1885
Mailing Address - Fax:479-872-1889
Practice Address - Street 1:1675 W JEFFERSON ST STE E
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-3001
Practice Address - Country:US
Practice Address - Phone:479-373-2510
Practice Address - Fax:479-373-2509
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHOSOURCE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-05
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161293716Medicaid