Provider Demographics
NPI:1982061487
Name:SPINAL SOURCE CHIROPRACTIC LLC
Entity type:Organization
Organization Name:SPINAL SOURCE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLLIG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-642-4945
Mailing Address - Street 1:6546 HAMPTON ROADS PKWY
Mailing Address - Street 2:STE 112
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3185
Mailing Address - Country:US
Mailing Address - Phone:757-296-2225
Mailing Address - Fax:757-977-1039
Practice Address - Street 1:6546 HAMPTON ROADS PKWY
Practice Address - Street 2:SUITE 112
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3185
Practice Address - Country:US
Practice Address - Phone:757-642-4945
Practice Address - Fax:757-977-1039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-28
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11751111N00000X
FL11140111N00000X
VA0104-557378111N00000X
VA0104-557380111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty