Organization
LIFESOURCE PRIME INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PEGGY BADDOUR (PRESIDENT/OWNER)
(910) 742-9243
Entity
Organization
Contact information
Practice address
939 SPRINGDALE DR, CLINTON, SC 29325-7266
(910) 742-9243
(888) 746-1787
Mailing address
PO BOX 740343, ATLANTA, GA 30374-0343
(910) 338-2885
(864) 626-0412
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
207R00000X
Internal Medicine Physician
—
—
208D00000X
General Practice Physician
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
363LF0000X
Family Nurse Practitioner
—
—
363LG0600X
Gerontology Nurse Practitioner
—
—
363LP2300X
Primary Care Nurse Practitioner
—
—
Other
Enumeration date
04/04/2024
Last updated
10/28/2025
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