Provider Demographics
NPI:1114295284
Name:HEALTHSOURCE OF CEDAR RAPIDS SW, LLC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF CEDAR RAPIDS SW, LLC
Other - Org Name:HEALTHSOURCE OF CEDAR RAPIDS SOUTHWEST P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RORY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MORAVETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:319-390-2037
Mailing Address - Street 1:3726 QUEEN CT SW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-3903
Mailing Address - Country:US
Mailing Address - Phone:319-373-7576
Mailing Address - Fax:
Practice Address - Street 1:3726 QUEEN CT SW
Practice Address - Street 2:SUITE 103
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-3903
Practice Address - Country:US
Practice Address - Phone:319-373-7576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06595111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty