Provider Demographics
NPI:1700364049
Name:HEALTHSOURCE OF MUSCLE SHOALS
Entity Type:Organization
Organization Name:HEALTHSOURCE OF MUSCLE SHOALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:GVILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:256-520-9369
Mailing Address - Street 1:3312 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-3332
Mailing Address - Country:US
Mailing Address - Phone:256-520-9369
Mailing Address - Fax:256-251-6220
Practice Address - Street 1:3312 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-3332
Practice Address - Country:US
Practice Address - Phone:256-520-9369
Practice Address - Fax:256-251-6220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2575111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1730666223OtherCHIROPRACTOR