Provider Demographics
NPI:1063749265
Name:SOURCE 1
Entity type:Organization
Organization Name:SOURCE 1
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-952-0396
Mailing Address - Street 1:3012 MICA CT
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:CO
Mailing Address - Zip Code:80027-4548
Mailing Address - Country:US
Mailing Address - Phone:303-952-0396
Mailing Address - Fax:303-595-5262
Practice Address - Street 1:1615 FOXTRAIL DR STE 190
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-9087
Practice Address - Country:US
Practice Address - Phone:303-952-0396
Practice Address - Fax:303-595-5262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4274647332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38059525Medicaid