Provider Demographics
NPI:1396217527
Name:THE SOURCE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:THE SOURCE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BILQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-978-0951
Mailing Address - Street 1:1275 WESTFIELD AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-1900
Mailing Address - Country:US
Mailing Address - Phone:732-978-0951
Mailing Address - Fax:
Practice Address - Street 1:1275 WESTFIELD AVE STE 1
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-1900
Practice Address - Country:US
Practice Address - Phone:732-978-0951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty