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General NPI Number Information
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NPI Number | 1326755760
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Entity Type | Organization
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Legal Business Name | LIFESOURCE, LLC.
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Dates
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Enumeration Date | 11/04/2022
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Last Update Date | 11/04/2022
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Provider Practice Location Address
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Address Line | 117 PARK AVE
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City | HAMILTON
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State | OH
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Zip | 45013-3120
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Country | US
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Telephone | 513-609-4796
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Fax |
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Provider Business Mailing Address
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Address Line | 117 PARK AVE
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City | HAMILTON
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State | OH
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Zip | 45013-3120
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Country | US
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Telephone | 513-609-4796
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. FREDERICK LEE MCQUEEN
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Credential | BCCMMHC
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Telephone | 513-609-4796
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number |
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License Number State |
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