Provider Demographics
NPI:1821535428
Name:LIFESOURCE OF NORTH CAROLINA
Entity Type:Organization
Organization Name:LIFESOURCE OF NORTH CAROLINA
Other - Org Name:LIFESOURCE OF ALABAMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:BADDOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-777-9165
Mailing Address - Street 1:PO BOX 538622
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1424 MONTCLAIR RD
Practice Address - Street 2:
Practice Address - City:IRONDALE
Practice Address - State:AL
Practice Address - Zip Code:35210-2208
Practice Address - Country:US
Practice Address - Phone:910-742-9243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESOURCE OF NORTH CAROLINA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-21
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty