Provider Demographics
NPI:1700068491
Name:LIFESOURCE CHIROPRACTIC P.C
Entity Type:Organization
Organization Name:LIFESOURCE CHIROPRACTIC P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:UNGARO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:212-286-0888
Mailing Address - Street 1:535 5TH AVE
Mailing Address - Street 2:SUITE 920
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-3620
Mailing Address - Country:US
Mailing Address - Phone:917-861-2472
Mailing Address - Fax:866-291-8321
Practice Address - Street 1:535 5TH AVE
Practice Address - Street 2:SUITE 920
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-3620
Practice Address - Country:US
Practice Address - Phone:212-286-0888
Practice Address - Fax:212-286-9726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009921111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty