Provider Demographics
NPI:1821078577
Name:MEDI-SOURCE EQUIPMENT & SUPPLY INC
Entity Type:Organization
Organization Name:MEDI-SOURCE EQUIPMENT & SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ESTA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-365-6389
Mailing Address - Street 1:PO BOX 712
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92286-0712
Mailing Address - Country:US
Mailing Address - Phone:760-365-6389
Mailing Address - Fax:760-365-7016
Practice Address - Street 1:57725 TWENTYNINE PALMS HWY
Practice Address - Street 2:SUITE 402
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-3046
Practice Address - Country:US
Practice Address - Phone:760-365-6389
Practice Address - Fax:760-365-7016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53366332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02109FMedicaid
0956800001Medicare ID - Type Unspecified