Provider Demographics
NPI:1710341847
Name:ONE SOURCE WELLNESS AND CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:ONE SOURCE WELLNESS AND CHIROPRACTIC LLC
Other - Org Name:ONE SOURCE WELLNESS AND CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DC
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:RALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-751-7505
Mailing Address - Street 1:13730 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-7115
Mailing Address - Country:US
Mailing Address - Phone:262-751-7505
Mailing Address - Fax:
Practice Address - Street 1:13730 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-7115
Practice Address - Country:US
Practice Address - Phone:262-751-7505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3958-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI111N00000XOtherTAXONOMY CHIROPRACTOR
WI38947700Medicaid
WI38947700Medicaid