MEDICARE: SOURCE ONE MOBILITY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BX2000X	Oxygen Equipment & Supplies (DME)	5596831-1714	UT

General Provider Information

NPI Number	:	1093924730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOURCE ONE MOBILITY LLC

Provider Business Mailing Address
First Line	:	4455 S 700 E
Second Line	:	SUITE 200
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-3153
Country	:	US
Telephone Number	:	801-281-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	4455 S 700 E
Second Line	:	SUITE 200
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-3153
Country	:	US
Telephone Number	:	801-281-4500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ROBERT GALLUP
Credential	:
Telephone Number	:	801-281-4500

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	08/22/2020

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Directions to “SOURCE ONE MOBILITY LLC ” Practice Location

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