| Organization Name: | HEALTHSOURCE OF LAKE BOONE TRAIL, PLLC |
| NPI Number: | 1255616611 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LISA C EVANS (BILLING MANAGER) |
| Mailing Address: | 4025 Lake Boone Trl Suite 120 Raleigh |
| State: | NC US |
| Postal Code: | 276072986 |
| Phone Number: | 9197859191 |
| Fax Number: | 9197859193 |
| NPI Enumeration Date: | 10/18/2011 |
| NPI Last Update Date: | 11/10/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | 3364 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NC |
| Taxonomy Type: | Chiropractic Providers |
| Taxonomy Classification: | Chiropractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |