Provider Demographics
NPI:1194852483
Name:ONE SOURCE FAMILY CHIROPRACTIC PA
Entity Type:Organization
Organization Name:ONE SOURCE FAMILY CHIROPRACTIC PA
Other - Org Name:ONE SOURCE FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-392-5750
Mailing Address - Street 1:132 JACKSON LN
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7222
Mailing Address - Country:US
Mailing Address - Phone:512-392-5750
Mailing Address - Fax:512-392-5320
Practice Address - Street 1:132 JACKSON LN
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7222
Practice Address - Country:US
Practice Address - Phone:512-392-5750
Practice Address - Fax:512-392-5320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF006540111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0078MNOtherBLUE CROSS BLUE SHIELD
TX0078MNOtherBLUE CROSS BLUE SHIELD