Organization
MEDSOURCE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ERIC ROHDE (OWNER)
(309) 664-7930
Entity
Organization
Contact information
Practice address
25835 NARBONNE AVE, SUITE 280D, LOMITA, CA 90717-3074
(888) 510-5100
Mailing address
PO BOX 1248, BLOOMINGTON, IL 61702-1248
(309) 664-7930
(309) 664-7931
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
203.000461
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
203.000461
LICENSE
IL
Enumeration date
03/09/2010
Last updated
06/27/2012
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