Provider Demographics
NPI:1679023154
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 1:6 EAST MAIN STREET
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CLINTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08809
Mailing Address - Country:US
Mailing Address - Phone:908-399-3499
Mailing Address - Fax:
Practice Address - Street 1:6 EAST MAIN STREET
Practice Address - Street 2:SUITE 6
Practice Address - City:CLINTON
Practice Address - State:NJ
Practice Address - Zip Code:08809
Practice Address - Country:US
Practice Address - Phone:908-399-3499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC05797111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty