Provider Demographics
NPI:1326223082
Name:LIFE SOURCE MEDICAL, INC.
Entity Type:Organization
Organization Name:LIFE SOURCE MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:P
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-316-1166
Mailing Address - Street 1:1439 MAIN STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740
Mailing Address - Country:US
Mailing Address - Phone:304-431-3000
Mailing Address - Fax:304-431-3330
Practice Address - Street 1:1439 MAIN STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-431-3000
Practice Address - Fax:304-431-3330
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE SOURCE MEDICAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies