Provider Demographics
NPI:1578805545
Name:BRISTOL CHIROPRACTIC AND WELLNESS CENTER, PC
Entity Type:Organization
Organization Name:BRISTOL CHIROPRACTIC AND WELLNESS CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:REED
Authorized Official - Last Name:BOOHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:423-968-2288
Mailing Address - Street 1:615 VOLUNTEER PKWY
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-3640
Mailing Address - Country:US
Mailing Address - Phone:423-968-2288
Mailing Address - Fax:423-968-4841
Practice Address - Street 1:615 VOLUNTEER PKWY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-3640
Practice Address - Country:US
Practice Address - Phone:423-968-2288
Practice Address - Fax:423-968-4841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000001489111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1053626507OtherNPI INDIVIDUAL
TN1526255Medicaid
TN1053626507OtherNPI INDIVIDUAL