Provider Demographics
NPI:1972824738
Name:HEALTHSOURCE OF CEDAR RAPIDS PC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF CEDAR RAPIDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WISDO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-508-9036
Mailing Address - Street 1:206 COLLINS RD NE STE 102
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-3165
Mailing Address - Country:US
Mailing Address - Phone:319-373-7576
Mailing Address - Fax:
Practice Address - Street 1:206 COLLINS RD NE STE 102
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-3165
Practice Address - Country:US
Practice Address - Phone:319-373-7576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty