Provider Demographics
NPI:1396707139
Name:LIFE SOURCE SERVICES LLC
Entity type:Organization
Organization Name:LIFE SOURCE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPA
Authorized Official - Prefix:MS
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ETINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-231-1412
Mailing Address - Street 1:245 S BENTON ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-2453
Mailing Address - Country:US
Mailing Address - Phone:303-231-1203
Mailing Address - Fax:303-234-0124
Practice Address - Street 1:700 KINDERKAMACK RD STE 105
Practice Address - Street 2:
Practice Address - City:ORADELL
Practice Address - State:NJ
Practice Address - Zip Code:07649
Practice Address - Country:US
Practice Address - Phone:888-865-5103
Practice Address - Fax:201-225-4769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22933251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8608709Medicaid
NJ311549Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER