Healthcare Provider Details

I. General information

NPI: 1619972239
Provider Name (Legal Business Name): SOURCE ONE MEDICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 TECHNOLOGY DR SUITE 165
IRVINE CA
92618-2328
US

IV. Provider business mailing address

16 TECHNOLOGY DR SUITE165
IRVINE CA
92618-2328
US

V. Phone/Fax

Practice location:
  • Phone: 888-447-9056
  • Fax: 949-387-6371
Mailing address:
  • Phone: 888-447-9056
  • Fax: 949-387-6371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number103616
License Number StateCA

VIII. Authorized Official

Name: DENNIS KLINE
Title or Position: PRESIDENT/CEO
Credential:
Phone: 888-447-9056