Provider Demographics
NPI:1689912263
Name:MEDISOURCE, INC
Entity Type:Organization
Organization Name:MEDISOURCE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:STEELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-412-2639
Mailing Address - Street 1:555 N EL CAMINO REAL
Mailing Address - Street 2:A376
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-6740
Mailing Address - Country:US
Mailing Address - Phone:949-412-2639
Mailing Address - Fax:888-500-0171
Practice Address - Street 1:555 N EL CAMINO REAL
Practice Address - Street 2:A376
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-6740
Practice Address - Country:US
Practice Address - Phone:949-412-2639
Practice Address - Fax:888-500-0171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies