MEDICARE: CENTERSOURCE CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	293D00000X	Physiological Laboratory

General Provider Information

NPI Number	:	1467881706
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTERSOURCE CORPORATION

Provider Business Mailing Address
First Line	:	2988 NW FAIRWAY HEIGHTS DR
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-8334
Country	:	US
Telephone Number	:	877-293-1472
Fax Number	:	877-293-1475

Provider Business Practice Location Address
First Line	:	2988 NW FAIRWAY HEIGHTS DR
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-8334
Country	:	US
Telephone Number	:	877-293-1472
Fax Number	:	877-293-1475

Authorized Official
Title or Position	:	FOUNDER
Name	:	KEVIN HOFFMAN
Credential	:
Telephone Number	:	877-293-1472

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	02/07/2017

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