Provider Demographics
NPI:1639042930
Name:CHIROSOURCE REHABILITATION LLC
Entity type:Organization
Organization Name:CHIROSOURCE REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:FORBES
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-741-2644
Mailing Address - Street 1:2425 W NINE MILE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32534-9469
Mailing Address - Country:US
Mailing Address - Phone:850-741-2644
Mailing Address - Fax:850-792-1354
Practice Address - Street 1:2425 W NINE MILE RD STE 1
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32534-9469
Practice Address - Country:US
Practice Address - Phone:850-741-2644
Practice Address - Fax:850-792-1354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-24
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty