Organization
THE SOURCE OF AMERICALLC
Active
Other names
the source d.a.g.
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RICK WHITE SR. (DIRECTOR)
(904) 703-4364
Entity
Organization
Contact information
Practice address
5301 GODDARD AVE, ORLANDO, FL 32810-5437
(407) 715-6807
Mailing address
5301 GODDARD AVE, ORLANDO, FL 32810-5437
(407) 715-6807
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
RAENISHA22
—
FL
Enumeration date
04/10/2012
Last updated
04/10/2012
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