Provider Demographics
NPI:1073754032
Name:LIFE SOURCE CREATING WELLNESS CTR INC
Entity Type:Organization
Organization Name:LIFE SOURCE CREATING WELLNESS CTR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:M
Authorized Official - Last Name:UPCHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:615-441-6115
Mailing Address - Street 1:491 HENSLEE DR
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-2166
Mailing Address - Country:US
Mailing Address - Phone:615-441-6115
Mailing Address - Fax:615-441-5154
Practice Address - Street 1:491 HENSLEE DR
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2166
Practice Address - Country:US
Practice Address - Phone:615-441-6115
Practice Address - Fax:615-441-5154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-20
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1444111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU69145Medicare UPIN