Healthcare Provider Details

I. General information

NPI: 1811286156
Provider Name (Legal Business Name): LIFESOURCE OF NORTH CAROLINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 RANDALL PKWY SUITE 105
WILMINGTON NC
28403
US

IV. Provider business mailing address

PO BOX 538622 LIFESOURCE OF NORTH CAROLINA
ATLANTA GA
30353-8622
US

V. Phone/Fax

Practice location:
  • Phone: 910-742-9243
  • Fax: 888-746-1787
Mailing address:
  • Phone: 910-742-9243
  • Fax: 888-746-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PEGGY L BADDOUR
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 910-777-9165