Provider Demographics
NPI:1245775501
Name:CROSSROADS SPINE & WELLNESS,LLC
Entity Type:Organization
Organization Name:CROSSROADS SPINE & WELLNESS,LLC
Other - Org Name:CROSSROADS SPINE & WELLNESS, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:DR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCSKULIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-654-2400
Mailing Address - Street 1:5391 HIGHWAY 53
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-3135
Mailing Address - Country:US
Mailing Address - Phone:706-654-2400
Mailing Address - Fax:
Practice Address - Street 1:5391 HIGHWAY 53
Practice Address - Street 2:SUITE 108
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-3135
Practice Address - Country:US
Practice Address - Phone:706-654-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-22
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002968111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty