Active NPI
Life Source Services, LLC
Doing business as Pax Hospice (Madison)
- Community Based Hospice Care Agency
- Madison, MS
National Provider Identifier
1417915091
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Community Based Hospice Care Agency
- License
- 079
- Legal business name
- LIFE SOURCE SERVICES, LLC
- Doing business as
- Pax Hospice (Madison)
- Practice address
- 129 Executive Dr
Suite C
Madison, MS 39110-8473 - Phone
- (601) 898-1510
- Fax
- (601) 898-1560
- NPI assigned
- May 3, 2006
- Last updated
- Jan 14, 2021
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Ms. Toni Parkinson
- Title
- Authorized Representative
- Phone
- (601) 709-1408
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community Based Hospice Care Agency | 251G00000X | 079 | LA | Primary |
Addresses
Primary practice location
129 Executive Dr
Suite C
Madison, MS 39110-8473
Mailing address
129 Executive Dr
Suite C
Madison, MS 39110-8473
Phone (601) 898-1510
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 02580708 | Medicaid | MS |
Other names 1
- Pax Hospice (Madison)
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MS
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050701000137 | MS | Part A Provider - Hospice | 1557307311 | Practice locations: Ridgeland, MS |
NPI to CCN mapping 1
The Medicare certification numbers (CCNs) connected to NPI 1417915091. Details of each certification follow.
Hospice certification: CCN 251574
- Legal name
- LIFE SOURCE SERVICES, LLC
- Doing business as
- PAX HOSPICE
- Certification status
- Active
- Provider type (POS)
- Hospice
- Participating since
- Mar 7, 2003
- Last certification
- Dec 9, 2021
- Ownership / control type
- Proprietary - Corporation
- Organization structure
- LLC
- Enrollment address
- 359 Towne Center PL
Ste 500
Ridgeland, MS 39157-4862
Other NPIs with the same Medicare PAC ID 1
NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).
-
dba Pax Hospice
- Community Based Hospice Care Agency
- Ridgeland, MS
- NPI 1598539975
1557307311
Care Compare: Hospice
Medicare Care Compare- Listed as
- Pax Hospice
- Ownership
- For-Profit
- Certified
- Mar 7, 2003
- Medicare certification status
- Active
National Provider Directory
National Provider Directory- Tax ID family
- Life Source Services LLC
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
-
dba Pax Hospice
- Community Based Hospice Care Agency
- Ridgeland, MS
- NPI 1598539975
Locations
129 Executive Dr
Ste C
Madison, MS 39110
Phone (601) 898-1510
359 Towne Center Blvd
Ste 500
Ridgeland, MS 39157
Phone (601) 991-3840
Ownership & related parties
All disclosed owners & managing parties 9
As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.
| Name | Role | Since | Share |
|---|---|---|---|
| Hibernia Williams | 5% Or Greater Direct Ownership Interest | Nov 1, 2009 | 7.14% |
| Trucare Hospice, LLC | 5% Or Greater Direct Ownership Interest | Nov 1, 2009 | 50% |
| Charles B Kelly | 5% Or Greater Indirect Ownership Interest | Nov 1, 2009 | 50% |
| Michael Bradley | W-2 Managing Employee | Jun 30, 2014 | |
| Toni H Parkinson | Corporate Officer | Nov 15, 2015 | |
| Janice Fortune | W-2 Managing Employee | Apr 21, 2015 | |
| Ann Belton | 5% Or Greater Direct Ownership Interest | Nov 1, 2009 | 7.14% |
| David W Stallard | 5% Or Greater Direct Ownership Interest | Apr 1, 2025 | 15.48% |
| Bobby L Beebe | 5% Or Greater Direct Ownership Interest | Apr 1, 2025 | 15.48% |
Practitioners & affiliated clinicians
Practitioners 2
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.
-
- General Practice Physician
- Jackson, MS
- NPI 1285746511
-
- Nurse Practitioner
- Florence, MS
- NPI 1053355024
Affiliated clinicians 7
Clinicians who list this facility as an affiliation in Medicare Care Compare.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1146614400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1610582400000",
"number": "1417915091",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "129 EXECUTIVE DR",
"address_2": "SUITE C",
"city": "MADISON",
"state": "MS",
"postal_code": "391108473",
"telephone_number": "601-898-1510",
"fax_number": "601-898-1560"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "129 EXECUTIVE DR",
"address_2": "SUITE C",
"city": "MADISON",
"state": "MS",
"postal_code": "391108473",
"telephone_number": "601-898-1510",
"fax_number": "601-898-1560"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "LIFE SOURCE SERVICES, LLC",
"organizational_subpart": "NO",
"enumeration_date": "2006-05-03",
"last_updated": "2021-01-14",
"certification_date": "2021-01-14",
"status": "A",
"authorized_official_last_name": "PARKINSON",
"authorized_official_first_name": "TONI",
"authorized_official_title_or_position": "AUTHORIZED REPRESENTATIVE",
"authorized_official_telephone_number": "601-709-1408",
"authorized_official_name_prefix": "Ms."
},
"taxonomies": [
{
"code": "251G00000X",
"taxonomy_group": "",
"desc": "Hospice Care, Community Based",
"state": "LA",
"license": "079",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "02580708",
"state": "MS"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Pax Hospice (Madison)",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "Pax Hospice (Madison)",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Madison, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 14, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.