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General NPI Number Information
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NPI Number | 1629482021
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Entity Type | Organization
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Legal Business Name | SOURCE HEALING
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Dates
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Enumeration Date | 06/13/2014
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Last Update Date | 06/13/2014
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Provider Practice Location Address
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Address Line | 650 N DEARBORN ST STE 800
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City | CHICAGO
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State | IL
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Zip | 60654-3874
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Country | US
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Telephone | 312-335-9330
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Fax |
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Provider Business Mailing Address
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Address Line | 650 N DEARBORN ST STE 800
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City | CHICAGO
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State | IL
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Zip | 60654-3874
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Country | US
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Telephone | 312-335-9330
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Fax |
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | CHRISTIE JORDAN
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Credential |
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Telephone | 312-335-9330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 198-000696
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License Number State | IL
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