Provider Demographics
NPI:1831112614
Name:ORTHOSOURCE, INC.
Entity Type:Organization
Organization Name:ORTHOSOURCE, INC.
Other - Org Name:KIMLOR MEDICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HAL
Authorized Official - Last Name:DEJARNATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-872-1885
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 1:830B E ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-7113
Practice Address - Country:US
Practice Address - Phone:479-872-1885
Practice Address - Fax:479-872-1889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
AR011957332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161293716Medicaid
AR4499560001Medicare NSC