Provider Demographics
NPI:1790965267
Name:HEALTHSOURCE OF EAST LYME LLC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF EAST LYME LLC
Other - Org Name:SUNRISE WELLNESS CENTER LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOULDING
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-739-3927
Mailing Address - Street 1:126 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1606
Mailing Address - Country:US
Mailing Address - Phone:860-739-3927
Mailing Address - Fax:
Practice Address - Street 1:126 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1606
Practice Address - Country:US
Practice Address - Phone:860-739-3927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000310111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02966Medicare PIN