Provider Demographics
NPI:1083804785
Name:LIFE SOURCE MEDICAL, INC.
Entity Type:Organization
Organization Name:LIFE SOURCE MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GORGI
Authorized Official - Middle Name:
Authorized Official - Last Name:NAUMOVSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-571-1005
Mailing Address - Street 1:377 S SWING RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-2009
Mailing Address - Country:US
Mailing Address - Phone:336-316-1166
Mailing Address - Fax:336-316-1144
Practice Address - Street 1:377 S SWING RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27409-2009
Practice Address - Country:US
Practice Address - Phone:336-316-1166
Practice Address - Fax:336-316-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-28
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704697Medicaid
NC7704697Medicaid