Provider Demographics
NPI:1588215784
Name:THE SOURCE FL PROFESSIONAL SERVICES, LLC
Entity Type:Organization
Organization Name:THE SOURCE FL PROFESSIONAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KORCOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-288-2555
Mailing Address - Street 1:1730 E COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-5721
Mailing Address - Country:US
Mailing Address - Phone:954-288-2555
Mailing Address - Fax:
Practice Address - Street 1:1730 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-5721
Practice Address - Country:US
Practice Address - Phone:954-288-2555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-28
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty