Healthcare Provider Details

I. General information

NPI: 1639423247
Provider Name (Legal Business Name): SOURCE ROUTE PRODUCTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3795 E PARSONS POINT RD BOX 1047
HERNANDO FL
34442-7701
US

IV. Provider business mailing address

3795 E PARSONS POINT RD BOX 1047
HERNANDO FL
34442-7701
US

V. Phone/Fax

Practice location:
  • Phone: 202-480-9234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-12-12087
License Number StateFL

VIII. Authorized Official

Name: DR. KIMBERLY MILLS
Title or Position: MEMBER
Credential: PH.D, BCBA
Phone: 202-480-9234