Provider Demographics
NPI:1144492760
Name:HEALTHSOURCE OF CHERRYDALE
Entity type:Organization
Organization Name:HEALTHSOURCE OF CHERRYDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCAIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:864-268-9040
Mailing Address - Street 1:2718 WADE HAMPTON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-1165
Mailing Address - Country:US
Mailing Address - Phone:864-268-9040
Mailing Address - Fax:864-244-7091
Practice Address - Street 1:2718 WADE HAMPTON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-1165
Practice Address - Country:US
Practice Address - Phone:864-268-9040
Practice Address - Fax:864-244-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty