Provider Demographics
NPI:1063614683
Name:PRIDEMORE FAMILY CHIROPRACTIC PC
Entity type:Organization
Organization Name:PRIDEMORE FAMILY CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PRIDEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:423-928-4101
Mailing Address - Street 1:514 E WATAUGA AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4039
Mailing Address - Country:US
Mailing Address - Phone:423-928-4101
Mailing Address - Fax:423-928-0994
Practice Address - Street 1:514 E WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4039
Practice Address - Country:US
Practice Address - Phone:423-928-4101
Practice Address - Fax:423-928-0994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC00000001297111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty