Provider Demographics
NPI:1902144660
Name:MED-SOURCE HOMECARE SERVICES
Entity Type:Organization
Organization Name:MED-SOURCE HOMECARE SERVICES
Other - Org Name:MED-SOURCE HEALTHCARE SERVICES, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:UDEAGHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-265-0095
Mailing Address - Street 1:12926 DAIRY ASHFORD RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3293
Mailing Address - Country:US
Mailing Address - Phone:281-265-0095
Mailing Address - Fax:
Practice Address - Street 1:12926 DAIRY ASHFORD RD
Practice Address - Street 2:SUITE 150
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3293
Practice Address - Country:US
Practice Address - Phone:281-265-0095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MED-SOURCE HEALTHCARE SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX010184253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX012116667Medicaid
TX747128Medicare Oscar/Certification