=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578799664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSOURCE THERAPEUTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2009
-----------------------------------------------------
Last Update Date | 06/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7356 US HIGHWAY 64
-----------------------------------------------------
City | ROBERSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27871-9073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-353-7025
-----------------------------------------------------
Fax | 252-353-7028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 FOX HAVEN DR #A
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-9720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-353-7025
-----------------------------------------------------
Fax | 252-353-7028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | PHYLLIS SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-353-7025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------