Provider Demographics
NPI:1851693063
Name:SOURCE OF LIFE, INC
Entity Type:Organization
Organization Name:SOURCE OF LIFE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:786-344-3001
Mailing Address - Street 1:4011 W FLAGLER ST STE 301
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1643
Mailing Address - Country:US
Mailing Address - Phone:305-644-2800
Mailing Address - Fax:305-644-2101
Practice Address - Street 1:5500 SW 77TH CT APT 301
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4375
Practice Address - Country:US
Practice Address - Phone:786-344-1998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA59149261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy