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General NPI Number Information
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NPI Number | 1124460985
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Entity Type | Organization
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Legal Business Name | LIFE SOURCE, PC
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Dates
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Enumeration Date | 07/22/2013
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Last Update Date | 07/22/2013
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Provider Practice Location Address
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Address Line | 1108 KENTWORTH DR SUITE 704
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City | HOLLY SPRINGS
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State | NC
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Zip | 27540-3325
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Country | US
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Telephone | 919-552-9952
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Fax | 919-552-3062
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Provider Business Mailing Address
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Address Line | 1108 KENTWORTH DR SUITE 704
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City | HOLLY SPRINGS
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State | NC
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Zip | 27540-3325
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Country | US
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Telephone | 919-552-9952
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Fax | 919-552-3062
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Authorized Official
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Title or Position | OWNER
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Name | FEYISAYO ADEYINA
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Credential | MD
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Telephone | 919-552-9952
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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