Healthcare Provider Details

I. General information

NPI: 1891119731
Provider Name (Legal Business Name): SOURCE FOR WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2014
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 KAINS AVE STE 201
ALBANY CA
94706-1271
US

IV. Provider business mailing address

405 KAINS AVE STE 201
ALBANY CA
94706-1271
US

V. Phone/Fax

Practice location:
  • Phone: 510-526-7300
  • Fax: 888-503-9990
Mailing address:
  • Phone: 510-526-7300
  • Fax: 888-503-9990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC29670
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC6019
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT LITTLE
Title or Position: OWNER
Credential: D.C.
Phone: 510-526-7300