Provider Demographics
NPI:1073858239
Name:HEALTHSOURCE OF CLEVELAND PLLC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF CLEVELAND PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:J
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:423-710-2443
Mailing Address - Street 1:4645 N LEE HWY
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-4042
Mailing Address - Country:US
Mailing Address - Phone:423-710-2443
Mailing Address - Fax:423-475-6407
Practice Address - Street 1:4645 N LEE HWY
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4042
Practice Address - Country:US
Practice Address - Phone:423-710-2443
Practice Address - Fax:423-475-6407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2339111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty