Provider Demographics
NPI:1104107374
Name:CRAWFORDSVILLE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:CRAWFORDSVILLE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:765-362-1500
Mailing Address - Street 1:407 E MARKET ST
Mailing Address - Street 2:STE 102
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-1852
Mailing Address - Country:US
Mailing Address - Phone:765-362-1500
Mailing Address - Fax:765-361-8919
Practice Address - Street 1:407 E MARKET ST
Practice Address - Street 2:STE 102
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1852
Practice Address - Country:US
Practice Address - Phone:765-362-1500
Practice Address - Fax:765-361-8919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2015-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002470A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000729294OtherANTHEM PIN
IN201040410AMedicaid
IN201040410AMedicaid