Provider Demographics
NPI:1437721529
Name:ELK RIVER CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:ELK RIVER CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:EDGE
Authorized Official - Suffix:
Authorized Official - Credentials:CHIROPRACTOR
Authorized Official - Phone:904-521-6349
Mailing Address - Street 1:105 DAVIDSON ST E
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-3580
Mailing Address - Country:US
Mailing Address - Phone:931-557-5111
Mailing Address - Fax:931-557-5112
Practice Address - Street 1:105 DAVIDSON ST E
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-3580
Practice Address - Country:US
Practice Address - Phone:931-557-5111
Practice Address - Fax:931-967-5112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-16
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1831634542OtherNPI