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General NPI Number Information
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NPI Number | 1255616611
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Entity Type | Organization
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Legal Business Name | HEALTHSOURCE OF LAKE BOONE TRAIL, PLLC
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Dates
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Enumeration Date | 10/18/2011
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Last Update Date | 11/10/2011
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Provider Practice Location Address
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Address Line | 4025 LAKE BOONE TRL SUITE 120
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City | RALEIGH
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State | NC
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Zip | 27607-2986
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Country | US
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Telephone | 919-785-9191
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Fax | 919-785-9193
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Provider Business Mailing Address
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Address Line | 4025 LAKE BOONE TRAIL SUITE 120
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City | RALEIGH
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State | NC
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Zip | 27607-2986
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Country | US
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Telephone | 910-431-4330
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Fax |
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | MRS. LISA C EVANS
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Credential |
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Telephone | 919-585-7365
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 3364
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License Number State | NC
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