Provider Demographics
NPI:1811303084
Name:CHIROSOURCE, LLC
Entity type:Organization
Organization Name:CHIROSOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-864-3754
Mailing Address - Street 1:1041 N HASTINGS WAY
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-1986
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1041 N HASTINGS WAY
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-1986
Practice Address - Country:US
Practice Address - Phone:715-864-3754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1942612999111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty