# LIFESOURCE OF NORTH CAROLINA

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1386144418
- **Authorized official:** PEGGY BADDOUR (PRESIDENT/OWNER)
- **Authorized official phone:** (910) 777-9165

## Contact information

- **Practice address:** 1208 E PERSHING BLVD, CHEYENNE, WY 82001-3230
- **Practice address phone:** (910) 742-9243
- **Practice address fax:** (888) 746-1787
- **Mailing address:** PO BOX 538622, ATLANTA, GA 30353-8622
- **Mailing address phone:** (910) 742-9243
- **Mailing address fax:** (888) 746-1787

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 103TC0700X | Clinical Psychologist | — | NULL | — |
| 103TC0700X | Clinical Psychologist | — | — | — |
| 1041C0700X | Clinical Social Worker | — | NULL | — |
| 1041C0700X | Clinical Social Worker | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | — |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 2084P0800X | Psychiatry Physician | — | NULL | — |
| 2084P0800X | Psychiatry Physician | — | — | — |
| 208D00000X | General Practice Physician | — | NULL | Yes |
| 208D00000X | General Practice Physician | — | — | Yes |
| 363A00000X | Physician Assistant | — | NULL | — |
| 363A00000X | Physician Assistant | — | — | — |
| 363L00000X | Nurse Practitioner | — | NULL | — |
| 363L00000X | Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 02/15/2018
- **Last updated:** 03/25/2021