1750540456 NPI number — WE CARE LIFESOURCE, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750540456 NPI number — WE CARE LIFESOURCE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WE CARE LIFESOURCE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750540456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1004 E DR MARTIN LUTHER KING JR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANT CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33563-5712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-766-0863
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1004 E DR MARTIN LUTHER KING JR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANT CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33563-5712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-766-0863
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HARGROVE
Authorized Official First Name:
LAVONDA
Authorized Official Middle Name:
MOORE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
813-766-0863

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  320900000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6932215 96 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6932215 98 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".