Provider Demographics
NPI:1518301878
Name:LIGHTSOURCE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:LIGHTSOURCE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JODI
Authorized Official - Middle Name:NICHOLE
Authorized Official - Last Name:DINNERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:908-399-3499
Mailing Address - Street 1:16 LEIGH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08809-1412
Mailing Address - Country:US
Mailing Address - Phone:908-238-1081
Mailing Address - Fax:908-238-1082
Practice Address - Street 1:16 LEIGH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NJ
Practice Address - Zip Code:08809-1412
Practice Address - Country:US
Practice Address - Phone:908-238-1081
Practice Address - Fax:908-238-1082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC05797111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU91806Medicare UPIN