Provider Demographics
NPI:1396025151
Name:HEALTHSOURCE OF SOUTH LAKE LLC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF SOUTH LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DC/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:M BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-310-0150
Mailing Address - Street 1:2225 W SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 441
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6750
Mailing Address - Country:US
Mailing Address - Phone:817-310-0150
Mailing Address - Fax:817-310-0710
Practice Address - Street 1:2225 W SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 441
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6750
Practice Address - Country:US
Practice Address - Phone:817-310-0150
Practice Address - Fax:817-310-0710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty