Provider Demographics
NPI:1972611259
Name:CROSSROADS CHIROPRACTIC CENTER, INC.
Entity type:Organization
Organization Name:CROSSROADS CHIROPRACTIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JYLL
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:PIVNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:423-538-5800
Mailing Address - Street 1:5964 HIGHWAY 11 E
Mailing Address - Street 2:
Mailing Address - City:PINEY FLATS
Mailing Address - State:TN
Mailing Address - Zip Code:37686-4746
Mailing Address - Country:US
Mailing Address - Phone:423-538-5800
Mailing Address - Fax:423-538-5800
Practice Address - Street 1:5964 HIGHWAY 11 E
Practice Address - Street 2:
Practice Address - City:PINEY FLATS
Practice Address - State:TN
Practice Address - Zip Code:37686-4746
Practice Address - Country:US
Practice Address - Phone:423-538-5800
Practice Address - Fax:423-538-5800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2008-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1788111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3535619Medicaid
TN4012576OtherBCBS TN
TN3535619Medicare PIN