Provider Demographics
NPI:1306034806
Name:LIFE SOURCE HEALING CENTER, INC
Entity Type:Organization
Organization Name:LIFE SOURCE HEALING CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-369-3600
Mailing Address - Street 1:1492 PRINCE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2210
Mailing Address - Country:US
Mailing Address - Phone:706-369-3600
Mailing Address - Fax:706-208-0021
Practice Address - Street 1:1492 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2210
Practice Address - Country:US
Practice Address - Phone:706-369-3600
Practice Address - Fax:706-208-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO6863111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty