Provider Demographics
NPI:1881703684
Name:SOURCE ONE MEDICAL INC
Entity type:Organization
Organization Name:SOURCE ONE MEDICAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-447-9056
Mailing Address - Street 1:38 TESLA
Mailing Address - Street 2:SUITE 150
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-4669
Mailing Address - Country:US
Mailing Address - Phone:888-447-9056
Mailing Address - Fax:949-387-6371
Practice Address - Street 1:2124 S 156TH CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2503
Practice Address - Country:US
Practice Address - Phone:888-447-9056
Practice Address - Fax:949-387-6371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1265360010Medicare NSC