Provider Demographics
NPI:1235407560
Name:HEALTHSOURCE OF GREENVILLE-SOUTH
Entity Type:Organization
Organization Name:HEALTHSOURCE OF GREENVILLE-SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:ROEDEL
Authorized Official - Last Name:MCCAIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:864-325-6373
Mailing Address - Street 1:104 MAULDIN RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-1221
Mailing Address - Country:US
Mailing Address - Phone:864-272-0132
Mailing Address - Fax:
Practice Address - Street 1:104 MAULDIN RD
Practice Address - Street 2:SUITE G
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-1221
Practice Address - Country:US
Practice Address - Phone:864-272-0132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3562111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty