Provider Demographics
NPI:1417915091
Name:LIFE SOURCE SERVICES, LLC
Entity Type:Organization
Organization Name:LIFE SOURCE SERVICES, LLC
Other - Org Name:PAX HOSPICE (MADISON)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-1408
Mailing Address - Street 1:129 EXECUTIVE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8473
Mailing Address - Country:US
Mailing Address - Phone:601-898-1510
Mailing Address - Fax:601-898-1560
Practice Address - Street 1:129 EXECUTIVE DR
Practice Address - Street 2:SUITE C
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8473
Practice Address - Country:US
Practice Address - Phone:601-898-1510
Practice Address - Fax:601-898-1560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA079251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02580708Medicaid
MS02580708Medicaid
MS251574Medicare Oscar/Certification