Provider Demographics
NPI:1790022457
Name:1 SOURCE MEDICAL, LLC
Entity Type:Organization
Organization Name:1 SOURCE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANILDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-691-1510
Mailing Address - Street 1:1068 E LANDIS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-4042
Mailing Address - Country:US
Mailing Address - Phone:856-691-1510
Mailing Address - Fax:856-692-1389
Practice Address - Street 1:1068 E LANDIS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-4042
Practice Address - Country:US
Practice Address - Phone:856-691-1510
Practice Address - Fax:856-692-1389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment