Provider Demographics
NPI:1851584965
Name:HEALTHSOURCE OF MASON, INC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF MASON, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:513-398-2000
Mailing Address - Street 1:5230 KINGS MILLS RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-2319
Mailing Address - Country:US
Mailing Address - Phone:513-398-2000
Mailing Address - Fax:513-332-9098
Practice Address - Street 1:5230 KINGS MILLS RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-2319
Practice Address - Country:US
Practice Address - Phone:513-398-2000
Practice Address - Fax:513-332-9098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2177111NR0400X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9370291Medicare PIN
OH6007090001Medicare NSC