Provider Demographics
NPI:1134288970
Name:CROUCH, CHANTELLE LARAINE (DC)
Entity Type:Individual
Prefix:DR
First Name:CHANTELLE
Middle Name:LARAINE
Last Name:CROUCH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 NASHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-4038
Mailing Address - Country:US
Mailing Address - Phone:270-842-1955
Mailing Address - Fax:270-842-1508
Practice Address - Street 1:2709 NASHVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-4038
Practice Address - Country:US
Practice Address - Phone:270-842-1955
Practice Address - Fax:270-842-1508
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY4889111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYV04349Medicare UPIN
KY0958902Medicare PIN