Provider Demographics
NPI:1942566393
Name:THE SOURCE OF AMERICALLC
Entity type:Organization
Organization Name:THE SOURCE OF AMERICALLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:904-703-4364
Mailing Address - Street 1:5301 GODDARD AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-5437
Mailing Address - Country:US
Mailing Address - Phone:407-715-6807
Mailing Address - Fax:
Practice Address - Street 1:5301 GODDARD AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-5437
Practice Address - Country:US
Practice Address - Phone:407-715-6807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRAENISHA22Medicaid