| Organization Name: | HEALTHSOURCE OF PORTAGE, LLC |
| NPI Number: | 1619087871 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TODD JOSEPH BAUER (OWNER) |
| Mailing Address: | 306 W Cook St Portage |
| State: | WI US |
| Postal Code: | 539012108 |
| Phone Number: | 6087422225 |
| Fax Number: | 6087422235 |
| NPI Enumeration Date: | 08/30/2006 |
| NPI Last Update Date: | 04/22/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | 4029-012 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| 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. |