MEDICARE: LIFESOURCE,INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	C0734	OR

General Provider Information

NPI Number	:	1073954806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESOURCE,INC

Provider Business Mailing Address
First Line	:	PO BOX 724
Second Line	:
City	:	FOSTER
State	:	OR
Zip	:	97345-0724
Country	:	US
Telephone Number	:	541-409-1206
Fax Number	:	541-367-1995

Provider Business Practice Location Address
First Line	:	1266 44TH AVE
Second Line	:
City	:	SWEET HOME
State	:	OR
Zip	:	97386-1235
Country	:	US
Telephone Number	:	541-409-1206
Fax Number	:	541-367-1995

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PETER THOMAS KAUFFMAN
Credential	:	MA
Telephone Number	:	541-409-1206

Provider Enumeration Date	:	07/09/2013
Last Update Date	:	07/09/2013

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Directions to “LIFESOURCE,INC ” Practice Location

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