Provider Demographics
NPI:1033177365
Name:KRUTAK, JON R (DC)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:R
Last Name:KRUTAK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4924 FORT HENRY DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-3386
Mailing Address - Country:US
Mailing Address - Phone:423-239-7340
Mailing Address - Fax:423-239-7452
Practice Address - Street 1:4924 FORT HENRY DR
Practice Address - Street 2:SUITE E
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-3386
Practice Address - Country:US
Practice Address - Phone:423-239-7340
Practice Address - Fax:423-239-7452
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC1096111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3676970Medicaid
TN3058747OtherBLUE CROSS BLUE SHIELD
TNTN0102OtherUNITED HEALTHCARE
TNP00441207OtherRAILROAD MEDICARE
TNTN0104OtherJOHN DEERE
TN4324698OtherCIGNA
TN4324698OtherCIGNA
TNU46381Medicare UPIN