=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609008085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ONE SOURCE M EDIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2009
-----------------------------------------------------
Last Update Date | 08/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 RODNEY LN
-----------------------------------------------------
City | WESTBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11590-1651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-975-7183
-----------------------------------------------------
Fax | 888-268-9368
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1129
-----------------------------------------------------
City | COPIAGUE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11726-0898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-975-7183
-----------------------------------------------------
Fax | 516-833-5893
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | ELSIE CHAMBLEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 888-268-9368
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------