Provider Demographics
NPI:1437614575
Name:THE SOURCE STUDIO
Entity Type:Organization
Organization Name:THE SOURCE STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-444-8404
Mailing Address - Street 1:1938 SAGUACHE PL
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-2903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1213 W EISENHOWER BLVD
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-3128
Practice Address - Country:US
Practice Address - Phone:970-776-9466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-03
Last Update Date:2019-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty