Provider Demographics
NPI:1073941191
Name:TRI-STATE CLINIC OF CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:TRI-STATE CLINIC OF CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:931-993-1922
Mailing Address - Street 1:2686 HUNTSVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-7647
Mailing Address - Country:US
Mailing Address - Phone:931-993-1922
Mailing Address - Fax:
Practice Address - Street 1:2686 HUNTSVILLE HWY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-7647
Practice Address - Country:US
Practice Address - Phone:931-993-1922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2702111N00000X
TN2700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty