NPIMap

Organization Active NPI

Lifesource of North Carolina

  • General Practice Physician
  • Clinton, SC
National Provider Identifier
1972861789
Registry record updated May 17, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
Legal business name
LIFESOURCE OF NORTH CAROLINA
Practice address
939 Springdale Dr
Clinton, SC 29325-7266
Phone
(910) 742-9243
NPI assigned
Apr 30, 2012
Last updated
May 17, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 17, 2022

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

Authorized official

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

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X
General Practice PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208D00000X Primary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X

Addresses

Primary practice location

939 Springdale Dr
Clinton, SC 29325-7266

Mailing address

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

Other practice location 1

2101 Dutch Fork Rd
Chapin, SC 29036-7576
Phone (910) 742-9243

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120801000901 SC Part B Supplier - Clinic/Group Practice 7416132428 Receives reassigned benefits from 51 practitioners
Practice locations: Clinton, SC

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

Practitioners & affiliated clinicians

Practitioners 72

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.

View all 72

NPI Registry JSON

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

{
    "created_epoch": "1335744000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1652745600000",
    "number": "1972861789",
    "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",
            "fax_number": "888-746-1787"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "939 SPRINGDALE DR",
            "city": "CLINTON",
            "state": "SC",
            "postal_code": "293257266",
            "telephone_number": "910-742-9243"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2101 Dutch Fork Rd",
            "address_purpose": "LOCATION",
            "city": "Chapin",
            "state": "SC",
            "postal_code": "290367576",
            "country_code": "US",
            "telephone_number": "910-742-9243",
            "fax_number": "888-746-1787",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "LIFESOURCE OF NORTH CAROLINA",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-04-30",
        "last_updated": "2022-05-17",
        "certification_date": "2022-05-17",
        "status": "A",
        "authorized_official_last_name": "BADDOUR",
        "authorized_official_first_name": "PEGGY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT/OWNER",
        "authorized_official_telephone_number": "910-777-9165"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Clinton, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 17, 2022; 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.