Organization
LIFESOURCE PRIME INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TABITHA HOFFMAN (CREDENTIALING)
(910) 777-9165
Entity
Organization
Contact information
Practice address
1345 REDMOND CIR NW, ROME, GA 30165-1307
(910) 742-9243
(888) 746-1787
Mailing address
PO BOX 740343, ATLANTA, GA 30374-0343
(910) 742-9243
(888) 746-1787
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
Primary
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Enumeration date
12/18/2025
Last updated
12/18/2025
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