Provider Demographics
NPI:1699941211
Name:MEDSOURCE EQUIPMENT LLC
Entity type:Organization
Organization Name:MEDSOURCE EQUIPMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-262-8327
Mailing Address - Street 1:PO BOX 8816
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-0816
Mailing Address - Country:US
Mailing Address - Phone:423-262-8327
Mailing Address - Fax:423-262-8329
Practice Address - Street 1:3201 BRISTOL HWY
Practice Address - Street 2:SUITE 4
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1565
Practice Address - Country:US
Practice Address - Phone:423-262-8327
Practice Address - Fax:423-262-8329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-03
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0017898332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies