Provider Demographics
NPI:1528840279
Name:SOURCE OF LIFE CARE LLC
Entity type:Organization
Organization Name:SOURCE OF LIFE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PERPETUE
Authorized Official - Middle Name:
Authorized Official - Last Name:WANYANDWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-426-0966
Mailing Address - Street 1:12823 138TH LN
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-2439
Mailing Address - Country:US
Mailing Address - Phone:727-426-0966
Mailing Address - Fax:386-200-5982
Practice Address - Street 1:12823 138TH LN
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-2439
Practice Address - Country:US
Practice Address - Phone:727-426-0966
Practice Address - Fax:386-200-5982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health