Provider Demographics
NPI:1609004563
Name:LIFE SOURCE SOLUTIONS, INC
Entity Type:Organization
Organization Name:LIFE SOURCE SOLUTIONS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AVIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:ATTAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:951-522-9370
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501
Mailing Address - Country:US
Mailing Address - Phone:951-682-7143
Mailing Address - Fax:951-684-1135
Practice Address - Street 1:4107 MISSION INN AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501
Practice Address - Country:US
Practice Address - Phone:951-682-7143
Practice Address - Fax:951-684-1135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health