Healthcare Provider Details

I. General information

NPI: 1902155146
Provider Name (Legal Business Name): HEALTHSOURCE OF GILLETTE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E LAKEWAY RD STE 1000
GILLETTE WY
82718-6365
US

IV. Provider business mailing address

110 E LAKEWAY RD STE 1000
GILLETTE WY
82718-6365
US

V. Phone/Fax

Practice location:
  • Phone: 307-670-9426
  • Fax: 307-257-2569
Mailing address:
  • Phone: 307-670-9426
  • Fax: 307-257-2569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number703
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number703
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number703
License Number StateWY

VIII. Authorized Official

Name: DR. MATTHEW ARNIO
Title or Position: OWNER
Credential: D.C.
Phone: 307-670-9426