Provider Demographics
NPI:1164834420
Name:HEALTHCARE SOURCE LLC
Entity Type:Organization
Organization Name:HEALTHCARE SOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOODFELLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-227-1546
Mailing Address - Street 1:12230 FOREST HILL BLVD
Mailing Address - Street 2:SUITE 193
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-5700
Mailing Address - Country:US
Mailing Address - Phone:561-227-1546
Mailing Address - Fax:561-227-1547
Practice Address - Street 1:12230 FOREST HILL BLVD
Practice Address - Street 2:SUITE 193
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-5700
Practice Address - Country:US
Practice Address - Phone:561-227-1546
Practice Address - Fax:561-227-1547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30211585251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30211585OtherLICENSED NURSE REGISTRY