Basic Information
| Provider Information | |||||||||
| NPI: | 1518301878 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIGHTSOURCE CHIROPRACTIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 LEIGH ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088091412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082381081 | ||||||||
| FaxNumber: | 9082381082 | ||||||||
| Practice Location | |||||||||
| Address1: | 16 LEIGH ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088091412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082381081 | ||||||||
| FaxNumber: | 9082381082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2013 | ||||||||
| LastUpdateDate: | 04/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | DINNERMAN | ||||||||
| AuthorizedOfficialFirstName: | JODI | ||||||||
| AuthorizedOfficialMiddleName: | NICHOLE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9083993499 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | MC05797 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.