Provider Demographics
NPI:1952779092
Name:SOURASACK, STEVE
Entity Type:Individual
Prefix:
First Name:STEVE
Middle Name:
Last Name:SOURASACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SEA ISLE DR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75060-7710
Mailing Address - Country:US
Mailing Address - Phone:817-966-9968
Mailing Address - Fax:
Practice Address - Street 1:1100 SEA ISLE DR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75060-7710
Practice Address - Country:US
Practice Address - Phone:817-966-9968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-06
Last Update Date:2015-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies