Healthcare Provider Details

I. General information

NPI: 1609004563
Provider Name (Legal Business Name): LIFE SOURCE SOLUTIONS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4107 MISSION INN AVE
RIVERSIDE CA
92501
US

IV. Provider business mailing address

PO BOX 529
RIVERSIDE CA
92501
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-7143
  • Fax: 951-684-1135
Mailing address:
  • Phone: 951-682-7143
  • Fax: 951-684-1135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. AVIS C ATTAWAY
Title or Position: OWNER
Credential: LMFT
Phone: 951-522-9370