Provider Demographics
NPI:1497870059
Name:CROM, JOHN WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:CROM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N 2ND AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PROCTOR
Mailing Address - State:MN
Mailing Address - Zip Code:55810-2230
Mailing Address - Country:US
Mailing Address - Phone:218-722-4265
Mailing Address - Fax:218-722-4265
Practice Address - Street 1:215 N 2ND AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PROCTOR
Practice Address - State:MN
Practice Address - Zip Code:55810-2230
Practice Address - Country:US
Practice Address - Phone:218-722-4265
Practice Address - Fax:218-722-4265
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN002940111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3K196CROtherBCBS MN
MN231588OtherCHIROCARE ID
MN2940OtherMN LICENSE NUMBER
MN3K196CROtherBCBS MN