Provider Demographics
NPI:1750677407
Name:SENIOR HEALTH SOURCE LLC
Entity Type:Organization
Organization Name:SENIOR HEALTH SOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:251-533-6372
Mailing Address - Street 1:PO BOX 7872
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORT
Mailing Address - State:AL
Mailing Address - Zip Code:36577-7872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27440 COUNTY ROAD 13
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-6222
Practice Address - Country:US
Practice Address - Phone:251-533-6372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-087343364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102G705926Medicare UPIN