Provider Demographics
NPI:1619541901
Name:ONE SOURCE SURGICAL SUPPLIES LLC
Entity Type:Organization
Organization Name:ONE SOURCE SURGICAL SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAYANT
Authorized Official - Middle Name:K
Authorized Official - Last Name:THAKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:914-948-4878
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10602-0072
Mailing Address - Country:US
Mailing Address - Phone:914-948-4878
Mailing Address - Fax:866-486-4959
Practice Address - Street 1:125 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELMSFORD
Practice Address - State:NY
Practice Address - Zip Code:10523-3217
Practice Address - Country:US
Practice Address - Phone:914-948-4878
Practice Address - Fax:866-486-4959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY769733OtherANCILLARY PROVIDER