Provider Demographics
NPI:1811158546
Name:PROSOURCE THERAPEUTICS, LLC
Entity type:Organization
Organization Name:PROSOURCE THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-353-7025
Mailing Address - Street 1:102 FOX HAVEN DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-9720
Mailing Address - Country:US
Mailing Address - Phone:252-353-7025
Mailing Address - Fax:
Practice Address - Street 1:622 EAST BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2736
Practice Address - Country:US
Practice Address - Phone:252-353-7025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty