Provider Demographics
NPI:1356309199
Name:LIFE SOURCE SERVICES, LLC
Entity Type:Organization
Organization Name:LIFE SOURCE SERVICES, LLC
Other - Org Name:LIFE SOURCE SERVICES BATON ROUGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-1408
Mailing Address - Street 1:3049 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2277
Mailing Address - Country:US
Mailing Address - Phone:225-291-9421
Mailing Address - Fax:225-291-9743
Practice Address - Street 1:3049 S SHERWOOD FOREST BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2277
Practice Address - Country:US
Practice Address - Phone:225-291-9421
Practice Address - Fax:225-291-9743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA148251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1581071Medicaid
LA1581071Medicaid