Provider Demographics
NPI:1699957787
Name:ONE SOURCE DIAGNOSTICS, INC.
Entity type:Organization
Organization Name:ONE SOURCE DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:RRT-RCP
Authorized Official - Phone:828-781-7413
Mailing Address - Street 1:3314 16TH AVE SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CONOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28613-9694
Mailing Address - Country:US
Mailing Address - Phone:704-325-0810
Mailing Address - Fax:704-325-0812
Practice Address - Street 1:3314 16TH AVE SE
Practice Address - Street 2:SUITE 201
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-9694
Practice Address - Country:US
Practice Address - Phone:704-325-0810
Practice Address - Fax:704-325-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA-559261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic