Healthcare Provider Details

I. General information

NPI: 1972146124
Provider Name (Legal Business Name): EASTERN SOURCE SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10471 6 MILE CYPRESS PKWY STE 400
FORT MYERS FL
33966-6973
US

IV. Provider business mailing address

10471 6 MILE CYPRESS PKWY STE 400
FORT MYERS FL
33966-6973
US

V. Phone/Fax

Practice location:
  • Phone: 239-202-2160
  • Fax:
Mailing address:
  • Phone: 239-202-2160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: MARIA E ROSABAL PADRON
Title or Position: PRESIDENT/CEO
Credential:
Phone: 239-202-2160