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General NPI Number Information
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NPI Number | 1679859169
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Entity Type | Organization
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Legal Business Name | MEDSOURCE MEDICAL, LLC
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Dates
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Enumeration Date | 10/27/2011
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Last Update Date | 10/27/2011
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Provider Practice Location Address
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Address Line | 9883 S 500 W
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City | SANDY
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State | UT
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Zip | 84070-2561
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Country | US
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Telephone | 877-577-7767
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Fax | 801-727-0092
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Provider Business Mailing Address
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Address Line | 9883 S 500 W
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City | SANDY
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State | UT
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Zip | 84070-2561
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Country | US
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Telephone | 877-577-7767
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Fax | 801-727-0092
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Authorized Official
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Title or Position | COO
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Name | ROBERT ROSE
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Credential |
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Telephone | 877-577-7767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 8119067-1714
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License Number State | UT
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