Provider Demographics
NPI:1487170197
Name:ONE SOURCE OF THE GULF COAST INC.
Entity type:Organization
Organization Name:ONE SOURCE OF THE GULF COAST INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P.
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:228-875-3828
Mailing Address - Street 1:3004 BIENVILLE BLVD STE 1
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 1:1903 SPRING HILL AVE
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-2303
Practice Address - Country:US
Practice Address - Phone:251-459-8600
Practice Address - Fax:251-459-8601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-15
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier