MEDICARE: HEALTHSOURCE, 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	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	0000000879	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780756148
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHSOURCE, INC.

Provider Business Mailing Address
First Line	:	5211 HIGHWAY 153
Second Line	:	SUITE K
City	:	HIXSON
State	:	TN
Zip	:	37343-4956
Country	:	US
Telephone Number	:	423-648-2095
Fax Number	:

Provider Business Practice Location Address
First Line	:	5211 HIGHWAY 153
Second Line	:	SUITE K
City	:	HIXSON
State	:	TN
Zip	:	37343-4956
Country	:	US
Telephone Number	:	423-648-2095
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	REBECCA FORTNER
Credential	:
Telephone Number	:	423-648-2095

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	08/22/2020

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Directions to “HEALTHSOURCE, INC. ” Practice Location

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