Provider Demographics
NPI:1609123256
Name:HEALTHSOURCE OF PROVIDENCE LLC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF PROVIDENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:256-221-0163
Mailing Address - Street 1:485 PROVIDENCE MAIN STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35806-2673
Mailing Address - Country:US
Mailing Address - Phone:256-221-0163
Mailing Address - Fax:
Practice Address - Street 1:485 PROVIDENCE MAIN ST NW STE 100
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35806-4899
Practice Address - Country:US
Practice Address - Phone:256-327-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510I350037Medicare UPIN