Organization
MEDI-SOURCE EQUIPMENT & SUPPLY INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. ESTA E WILLMAN (PRESIDENT)
(760) 365-6389
Entity
Organization
Contact information
Practice address
57725 TWENTYNINE PALMS HWY, SUITE 402, YUCCA VALLEY, CA 92284-3046
(760) 365-6389
(760) 365-7016
Mailing address
PO BOX 712, YUCCA VALLEY, CA 92286-0712
(760) 365-6389
(760) 365-7016
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
53366
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
DME02109F
—
CA
Enumeration date
01/19/2006
Last updated
05/24/2010
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