Provider Demographics
NPI:1790981249
Name:EASTERN STAR LLC
Entity Type:Organization
Organization Name:EASTERN STAR LLC
Other - Org Name:WELLSPRING FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR (OWNER)
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:931-528-5284
Mailing Address - Street 1:280 S JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-3453
Mailing Address - Country:US
Mailing Address - Phone:931-528-5284
Mailing Address - Fax:931-520-1870
Practice Address - Street 1:280 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3453
Practice Address - Country:US
Practice Address - Phone:931-528-5284
Practice Address - Fax:931-520-1870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2108111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty