Organization
LIFESOURCE OF NORTH CAROLINA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PEGGY L BADDOUR (PRESIDENT/OWNER)
(910) 777-9165
Entity
Organization
Contact information
Practice address
3205 RANDALL PKWY, SUITE 105, WILMINGTON, NC 28403
(910) 742-9243
(888) 746-1787
Mailing address
PO BOX 538622, LIFESOURCE OF NORTH CAROLINA, ATLANTA, GA 30353-8622
(910) 742-9243
(888) 746-1787
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
—
—
1041C0700X
Clinical Social Worker
—
—
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
Primary
—
—
2084P0800X
Psychiatry Physician
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Enumeration date
04/06/2011
Last updated
12/29/2021
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