Provider Demographics
NPI:1891119731
Name:SOURCE FOR WELLNESS
Entity Type:Organization
Organization Name:SOURCE FOR WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:510-526-7300
Mailing Address - Street 1:405 KAINS AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1271
Mailing Address - Country:US
Mailing Address - Phone:510-526-7300
Mailing Address - Fax:888-503-9990
Practice Address - Street 1:405 KAINS AVE
Practice Address - Street 2:STE 201
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-1271
Practice Address - Country:US
Practice Address - Phone:510-526-7300
Practice Address - Fax:888-503-9990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29670111N00000X
CAAC6019171100000X
2255A2300X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty