Healthcare Provider Details

I. General information

NPI: 1356730352
Provider Name (Legal Business Name): LSSR MANAGEMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13777 JUDSON RD SUITE 107
SAN ANTONIO TX
78233-4514
US

IV. Provider business mailing address

PO BOX 47626
SAN ANTONIO TX
78265-8626
US

V. Phone/Fax

Practice location:
  • Phone: 847-975-4645
  • Fax:
Mailing address:
  • Phone: 847-975-4645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberTX12285
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License NumberTX12285
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberTX12285
License Number StateTX

VIII. Authorized Official

Name: COREY WILLIAM SORUM
Title or Position: VICE PRESIDENT/CLINIC DIRECTOR
Credential: DC
Phone: 847-975-4645