Healthcare Provider Details

I. General information

NPI: 1326755760
Provider Name (Legal Business Name): LIFESOURCE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 PARK AVE
HAMILTON OH
45013-3120
US

IV. Provider business mailing address

117 PARK AVE
HAMILTON OH
45013-3120
US

V. Phone/Fax

Practice location:
  • Phone: 513-609-4796
  • Fax:
Mailing address:
  • Phone: 513-609-4796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: MR. FREDERICK LEE MCQUEEN
Title or Position: CEO
Credential: BCCMMHC
Phone: 513-609-4796