Provider Demographics
NPI:1720225014
Name:PROSOURCE THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:PROSOURCE THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-353-7025
Mailing Address - Street 1:102 FOX HAVEN DR STE A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-9720
Mailing Address - Country:US
Mailing Address - Phone:252-353-7025
Mailing Address - Fax:
Practice Address - Street 1:201 E PITT ST
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-5192
Practice Address - Country:US
Practice Address - Phone:252-353-7025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017PNOtherNC BLUE CROSS BLUE SHIELD
NC6005734Medicaid