| Lifesource Prime Inc | |
|
939 Springdale Dr Clinton SC 29325-7266 | |
| (910) 742-9243 | |
| (888) 746-1787 |
| Full Name | Lifesource Prime Inc |
|---|---|
| Speciality | Family Medicine |
| Location | 939 Springdale Dr, Clinton, South Carolina |
| Authorized Official Name and Position | Peggy Baddour (PRESIDENT/OWNER) |
| Authorized Official Contact | 9107429243 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lifesource Prime Inc Po Box 538622 Atlanta GA 30353-8622 Ph: (910) 338-2885 | Lifesource Prime Inc 939 Springdale Dr Clinton SC 29325-7266 Ph: (910) 742-9243 |
| NPI Number | 1851143523 |
|---|---|
| Provider Enumeration Date | 04/04/2024 |
| Last Update Date | 04/04/2024 |
| Medicare PECOS PAC ID | 7810336385 |
|---|---|
| Medicare Enrollment ID | O20240613002055 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1851143523 | NPI | - | NPPES |
| Provider Name | Monica M Denoux |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1003259235 PECOS PAC ID: 7012157456 Enrollment ID: I20130709000419 |
| Provider Name | Ishan Bhansaly |
|---|---|
| Provider Type | Practitioner - Hospitalist |
| Provider Identifiers | NPI Number: 1972824357 PECOS PAC ID: 6507004157 Enrollment ID: I20131003000071 |
| Provider Name | Michael Anthony Jones |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1568950426 PECOS PAC ID: 3577818780 Enrollment ID: I20180612001071 |
| Provider Name | Chacey Bryan |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1699228734 PECOS PAC ID: 9234425885 Enrollment ID: I20220404001270 |
| Provider Name | Megan Wolff |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1568114650 PECOS PAC ID: 2466831524 Enrollment ID: I20220620001738 |
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