Provider Demographics
NPI:1104015866
Name:HEALTHSOURCE OF NORTHWEST FLORIDA LLC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF NORTHWEST FLORIDA LLC
Other - Org Name:HEALTHSOURCE OF NW FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:RABINOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-473-5555
Mailing Address - Street 1:2122 W NINE MILE RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32534-9464
Mailing Address - Country:US
Mailing Address - Phone:850-473-5555
Mailing Address - Fax:850-473-5505
Practice Address - Street 1:2122 W NINE MILE RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32534-9464
Practice Address - Country:US
Practice Address - Phone:850-473-5555
Practice Address - Fax:850-473-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7205111N00000X
FLCH9112111N00000X
FLCH11561111N00000X
FLCH11826111N00000X
FLCH12186111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBM255AOtherMEDICARE PTAN
FLBM255AOtherMEDICARE PTAN
FLU49030Medicare UPIN