Provider Demographics
NPI:1811284235
Name:HEALTHSOURCE CHIROPRACTIC AND PROGRESSIVE REHAB OF PELLA INC
Entity type:Organization
Organization Name:HEALTHSOURCE CHIROPRACTIC AND PROGRESSIVE REHAB OF PELLA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:GROENENDYK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:641-780-3375
Mailing Address - Street 1:618 WASHINGTON ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1556
Mailing Address - Country:US
Mailing Address - Phone:641-780-3375
Mailing Address - Fax:
Practice Address - Street 1:2720 E 40TH CT
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50317-5540
Practice Address - Country:US
Practice Address - Phone:641-780-3375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007228111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty