MEDICARE: SENIOR SOURCE ONE MEDICAL SUPPLIES AND SERVICES 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1629495650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENIOR SOURCE ONE MEDICAL SUPPLIES AND SERVICES LLC

Provider Business Mailing Address
First Line	:	1426 WOODLAND TER SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-3224
Country	:	US
Telephone Number	:	404-422-6659
Fax Number	:

Provider Business Practice Location Address
First Line	:	1426 WOODLAND TER SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-3224
Country	:	US
Telephone Number	:	404-422-6659
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. HARRIS EVERSON
Credential	:
Telephone Number	:	404-422-6659

Provider Enumeration Date	:	03/27/2014
Last Update Date	:	03/27/2014

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