Provider Demographics
NPI:1043584030
Name:HEALTHSOURCE OF SHALLOWFORD
Entity type:Organization
Organization Name:HEALTHSOURCE OF SHALLOWFORD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:JULIUS
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:423-475-6438
Mailing Address - Street 1:6102 SHALLOWFORD RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1684
Mailing Address - Country:US
Mailing Address - Phone:423-475-6438
Mailing Address - Fax:423-475-6407
Practice Address - Street 1:6102 SHALLOWFORD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1684
Practice Address - Country:US
Practice Address - Phone:423-475-6438
Practice Address - Fax:423-475-6407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty