Provider Demographics
NPI:1750540456
Name:WE CARE LIFESOURCE, INC
Entity type:Organization
Organization Name:WE CARE LIFESOURCE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LAVONDA
Authorized Official - Middle Name:MOORE
Authorized Official - Last Name:HARGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-766-0863
Mailing Address - Street 1:1004 E DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-5712
Mailing Address - Country:US
Mailing Address - Phone:813-766-0863
Mailing Address - Fax:
Practice Address - Street 1:1004 E DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-5712
Practice Address - Country:US
Practice Address - Phone:813-766-0863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320900000X320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6932215 96Medicaid
FL6932215 98Medicaid