Provider Demographics
NPI:1750510517
Name:CROUCH CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:CROUCH CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:CROUCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-812-2225
Mailing Address - Street 1:413 GREENVILLE ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-3360
Mailing Address - Country:US
Mailing Address - Phone:706-812-2225
Mailing Address - Fax:706-812-8966
Practice Address - Street 1:413 GREENVILLE ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-3360
Practice Address - Country:US
Practice Address - Phone:706-812-2225
Practice Address - Fax:706-812-8966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5885111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCDXMMedicare PIN