NPIMap

Organization Active NPI

Lifesource of North Carolina

  • Clinical Social Worker
  • Richmond, VA
National Provider Identifier
1114419124
Registry record updated Mar 25, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Social WorkerTaxonomy code 1041C0700X
Legal business name
LIFESOURCE OF NORTH CAROLINA
Practice address
1901 Libbie Ave
Richmond, VA 23226-1808
Phone
(910) 742-9243
Fax
(888) 746-1787
NPI assigned
Jun 5, 2018
Last updated
Mar 25, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 25, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Peggy Baddour
Title
President/Owner
Phone
(910) 777-9165

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X NU
Clinical Social Worker 1041C0700X NU Primary
Psychiatry Physician 2084P0800X NU
Physician Assistant 363A00000X NU
Nurse Practitioner 363L00000X NU

Addresses

Primary practice location

1901 Libbie Ave
Richmond, VA 23226-1808

Mailing address

PO Box 538622
Atlanta, GA 30353-8622
Phone (910) 742-9243

Other practice location 1

10307 W Broad St.
#309
Glen Allen, VA 23060-6716
Phone (910) 742-9243

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180806000818 VA Part B Supplier - Clinic/Group Practice 7416132428 Receives reassigned benefits from 6 practitioners
Practice locations: Richmond, VA

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Lifesource of Georgia8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1528156800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1616630400000",
    "number": "1114419124",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 538622",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303538622",
            "telephone_number": "910-742-9243"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1901 LIBBIE AVE",
            "city": "RICHMOND",
            "state": "VA",
            "postal_code": "232261808",
            "telephone_number": "910-742-9243",
            "fax_number": "888-746-1787"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "10307 W Broad St.",
            "address_2": "#309",
            "address_purpose": "LOCATION",
            "city": "Glen Allen",
            "state": "VA",
            "postal_code": "230606716",
            "country_code": "US",
            "telephone_number": "910-742-9243",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "LIFESOURCE OF NORTH CAROLINA",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-06-05",
        "last_updated": "2021-03-25",
        "certification_date": "2021-03-25",
        "status": "A",
        "authorized_official_last_name": "BADDOUR",
        "authorized_official_first_name": "PEGGY",
        "authorized_official_title_or_position": "PRESIDENT/OWNER",
        "authorized_official_telephone_number": "910-777-9165"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Richmond, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.