- Enrollment id
- O20200421000057
- Enrollment state
- CA
- Provider type code
- 00-08
- Provider type text
- PART A PROVIDER - HOSPICE
- Npi
- 1033740758
- Multiple npi flag
- N
- Ccn
- A11646
- Associate id
- 0446680128
- Organization name
- LIFE SOURCE HOSPICE INC
- Incorporation date
- 2019-04-30
- Incorporation state
- CA
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- P
- Address line 1
- 6819 SEPULVEDA BLVD
- Address line 2
- STE 209
- City
- VAN NUYS
- State
- CA
- Zip code
- 914054440