Healthcare Provider Details

I. General information

NPI: 1366653545
Provider Name (Legal Business Name): ONE SOURCE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2007
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13910 LYNMAR BLVD
TAMPA FL
33626
US

IV. Provider business mailing address

13910 LYNMAR BLVD
TAMPA FL
33626-3123
US

V. Phone/Fax

Practice location:
  • Phone: 813-792-3560
  • Fax: 877-490-9111
Mailing address:
  • Phone: 866-834-7473
  • Fax: 877-490-9111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1313496
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: DANIEL J ROBICHAUD
Title or Position: CEO
Credential:
Phone: 866-834-7473