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General NPI Number Information
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NPI Number | 1639512171
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Entity Type | Organization
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Legal Business Name | MEDISOURCE HOME HEALTH
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Dates
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Enumeration Date | 04/15/2013
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 406 W COLLEGE BLVD STE A
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City | ROSWELL
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State | NM
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Zip | 88201-5114
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Country | US
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Telephone | 575-910-5521
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Fax | 575-208-1769
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Provider Business Mailing Address
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Address Line | 406 W COLLEGE BLVD STE A
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City | ROSWELL
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State | NM
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Zip | 88201-5114
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Country | US
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Telephone | 575-910-5521
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Fax | 575-208-1769
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Authorized Official
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Title or Position | ADMINISTRATOR/OWNER
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Name | REBECCA L THOMPSON-RAMIREZ
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Credential | RN
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Telephone | 575-910-5521
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 3434
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License Number State | NM
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