Provider Demographics
NPI:1003257031
Name:VITASOURCE CHIROPRACTIC & REHABILITATION LLC
Entity Type:Organization
Organization Name:VITASOURCE CHIROPRACTIC & REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:FONTAINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-276-2250
Mailing Address - Street 1:1831 W CHELTENHAM AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1049
Mailing Address - Country:US
Mailing Address - Phone:215-276-2250
Mailing Address - Fax:215-276-2110
Practice Address - Street 1:1831 W CHELTENHAM AVE
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-1049
Practice Address - Country:US
Practice Address - Phone:215-276-2250
Practice Address - Fax:215-276-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010306111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0100XChiropractic ProvidersChiropractorOccupational HealthGroup - Single Specialty