Basic Information
| Provider Information | |||||||||
| NPI: | 1174168496 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFESOURCE OF NORTH CAROLINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 538622 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303538622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107429243 | ||||||||
| FaxNumber: | 8887461787 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 MAIN ST S | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107429243 | ||||||||
| FaxNumber: | 8887461787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2019 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | BADDOUR | ||||||||
| AuthorizedOfficialFirstName: | PEGGY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9103382882 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.