MEDICARE: PROFORMA MEDICAL SOURC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1962429621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFORMA MEDICAL SOURC

Provider Business Mailing Address
First Line	:	800 N RAINBOW BLVD
Second Line	:	STE 215
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-1189
Country	:	US
Telephone Number	:	800-875-8455
Fax Number	:	702-948-7616

Provider Business Practice Location Address
First Line	:	800 N RAINBOW BLVD
Second Line	:	STE 215
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-1189
Country	:	US
Telephone Number	:	800-875-8455
Fax Number	:	702-948-7616

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MARIE VILLANUEVA
Credential	:
Telephone Number	:	800-875-8455

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	08/01/2008

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Directions to “PROFORMA MEDICAL SOURC ” Practice Location

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