MEDICARE: SOURCE ONE MEDICAL INC

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	:	1679736888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOURCE ONE MEDICAL INC

Provider Business Mailing Address
First Line	:	38 TESLA
Second Line	:	SUITE 150
City	:	IRVINE
State	:	CA
Zip	:	92618-4670
Country	:	US
Telephone Number	:	888-447-9056
Fax Number	:	888-845-0938

Provider Business Practice Location Address
First Line	:	6280 S VALLEY VIEW BLVD
Second Line	:	SUITE 220
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-3809
Country	:	US
Telephone Number	:	888-447-9056
Fax Number	:	888-845-0838

Authorized Official
Title or Position	:	ADM OFFICE MGR
Name	:	FRANK BRYAN
Credential	:
Telephone Number	:	888-447-9056

Provider Enumeration Date	:	07/08/2008
Last Update Date	:	07/08/2008

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Directions to “SOURCE ONE MEDICAL INC ” Practice Location

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