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General NPI Number Information
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NPI Number | 1841155181
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Entity Type | Organization
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Legal Business Name | LIFESOURCE PRIME INC
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Dates
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Enumeration Date | 12/18/2025
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Last Update Date | 12/18/2025
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Provider Practice Location Address
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Address Line | 1345 REDMOND CIR NW
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City | ROME
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State | GA
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Zip | 30165-1307
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Country | US
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Telephone | 910-742-9243
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Fax | 888-746-1787
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Provider Business Mailing Address
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Address Line | PO BOX 740343
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City | ATLANTA
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State | GA
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Zip | 30374-0343
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Country | US
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Telephone | 910-742-9243
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Fax | 888-746-1787
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Authorized Official
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Title or Position | CREDENTIALING
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Name | TABITHA HOFFMAN
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Credential |
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Telephone | 910-777-9165
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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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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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