Provider Demographics
NPI:1154953321
Name:ONE SOURCE INC.
Entity type:Organization
Organization Name:ONE SOURCE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-424-5222
Mailing Address - Street 1:3004 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4370
Mailing Address - Country:US
Mailing Address - Phone:228-875-3828
Mailing Address - Fax:228-436-3580
Practice Address - Street 1:1346 LINDBERG DR STE 8
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-8081
Practice Address - Country:US
Practice Address - Phone:228-875-3828
Practice Address - Fax:228-436-3580
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ONE SOURCE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-06
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2524534Medicaid