Provider Demographics
NPI:1316482474
Name:CROSSWAIT CHIROPRACTIC PC
Entity type:Organization
Organization Name:CROSSWAIT CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CROSSWAIT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-716-7711
Mailing Address - Street 1:1727 W MAIN ST
Mailing Address - Street 2:STE 2
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2500
Mailing Address - Country:US
Mailing Address - Phone:605-716-7711
Mailing Address - Fax:
Practice Address - Street 1:1727 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2500
Practice Address - Country:US
Practice Address - Phone:605-716-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-28
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1299111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty