Provider Demographics
NPI:1336577162
Name:HEALTHSOURCE OF FALL RIVER CHIROPRACTIC AND PROGRESSIVE WELLNESS, PC
Entity type:Organization
Organization Name:HEALTHSOURCE OF FALL RIVER CHIROPRACTIC AND PROGRESSIVE WELLNESS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:DERSHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:508-677-2554
Mailing Address - Street 1:657 PLEASANT ST
Mailing Address - Street 2:UNIT 9
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-4323
Mailing Address - Country:US
Mailing Address - Phone:508-677-2554
Mailing Address - Fax:508-677-2553
Practice Address - Street 1:657 PLEASANT ST
Practice Address - Street 2:UNIT 9
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-4323
Practice Address - Country:US
Practice Address - Phone:508-677-2554
Practice Address - Fax:508-677-2553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3339111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty