Basic Information
| Provider Information | |||||||||
| NPI: | 1073754032 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFE SOURCE CREATING WELLNESS CTR INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 491 HENSLEE DR | ||||||||
| Address2: | |||||||||
| City: | DICKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370552166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154416115 | ||||||||
| FaxNumber: | 6154415154 | ||||||||
| Practice Location | |||||||||
| Address1: | 491 HENSLEE DR | ||||||||
| Address2: | |||||||||
| City: | DICKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370552166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154416115 | ||||||||
| FaxNumber: | 6154415154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2009 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | UPCHURCH | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6154416115 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 1444 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.