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NPI Code Detail

MEDICARE: LIFESOURCE PRIME INC

MEDICARE: LIFESOURCE PRIME 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
1207Q00000XFamily Medicine Physician

General Provider Information

NPI Number : 1548124159
Entity Type Code : Organization
Provider Name (Legal Business Name) : LIFESOURCE PRIME INC
Provider Business Mailing Address
First Line : PO BOX 740343
Second Line :
City : ATLANTA
State : GA
Zip : 30374-0343
Country : US
Telephone Number : 910-338-2877
Fax Number : 877-335-9071
Provider Business Practice Location Address
First Line : 1901 LIBBIE AVE
Second Line :
City : RICHMOND
State : VA
Zip : 23226-1808
Country : US
Telephone Number : 910-742-9243
Fax Number : 888-746-1787
Authorized Official
Title or Position : VICE PRESIDENT OF OPERATIONS
Name : ERYN M ROBBINS
Credential :
Telephone Number : 910-622-2319
Provider Enumeration Date : 12/10/2025
Last Update Date : 12/10/2025

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Directions to “LIFESOURCE PRIME INC ” Practice Location

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