Provider Demographics
NPI:1902070964
Name:PRIME SOURCE MEDICAL SERVICES, INC
Entity type:Organization
Organization Name:PRIME SOURCE MEDICAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JADE
Authorized Official - Middle Name:U
Authorized Official - Last Name:IRONDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-687-6776
Mailing Address - Street 1:2715 MACKEY PL STE 116
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2528
Mailing Address - Country:US
Mailing Address - Phone:318-687-6776
Mailing Address - Fax:318-687-6996
Practice Address - Street 1:2715 MACKEY PL STE 116
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2528
Practice Address - Country:US
Practice Address - Phone:318-687-6776
Practice Address - Fax:318-687-6996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
LA00213555332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies