Provider Demographics
NPI:1619155801
Name:CROWDER CHIROPRACTIC REHAB
Entity Type:Organization
Organization Name:CROWDER CHIROPRACTIC REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:TERRANCE
Authorized Official - Last Name:CROWDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:502-776-0231
Mailing Address - Street 1:2021 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-1527
Mailing Address - Country:US
Mailing Address - Phone:502-776-0231
Mailing Address - Fax:502-776-7383
Practice Address - Street 1:2021 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-1527
Practice Address - Country:US
Practice Address - Phone:502-776-0231
Practice Address - Fax:502-776-7383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-10
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 4010111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85040103Medicaid
KY0756601Medicare PIN