Provider Demographics
NPI:1962429621
Name:PROFORMA MEDICAL SOURC
Entity type:Organization
Organization Name:PROFORMA MEDICAL SOURC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-875-8455
Mailing Address - Street 1:800 N RAINBOW BLVD
Mailing Address - Street 2:STE 215
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1189
Mailing Address - Country:US
Mailing Address - Phone:800-875-8455
Mailing Address - Fax:702-948-7616
Practice Address - Street 1:800 N RAINBOW BLVD
Practice Address - Street 2:STE 215
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1189
Practice Address - Country:US
Practice Address - Phone:800-875-8455
Practice Address - Fax:702-948-7616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV5345560001Medicare NSC