Provider Demographics
NPI:1942453329
Name:SOURCE CHIROPRACTIC & REHABILITATION, LLC
Entity Type:Organization
Organization Name:SOURCE CHIROPRACTIC & REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:504-324-5617
Mailing Address - Street 1:4033 VETERANS MEMORIAL BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-5525
Mailing Address - Country:US
Mailing Address - Phone:504-324-5617
Mailing Address - Fax:504-324-5618
Practice Address - Street 1:4033 VETERANS MEMORIAL BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-5525
Practice Address - Country:US
Practice Address - Phone:504-324-5617
Practice Address - Fax:504-324-5618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1364261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty