Provider Demographics
NPI:1891890869
Name:CROSS CREEK CHIROPRACTIC CLINIC PA
Entity Type:Organization
Organization Name:CROSS CREEK CHIROPRACTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:THORNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-323-5522
Mailing Address - Street 1:517 BEAUMONT RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4424
Mailing Address - Country:US
Mailing Address - Phone:910-323-5522
Mailing Address - Fax:
Practice Address - Street 1:517 BEAUMONT RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4424
Practice Address - Country:US
Practice Address - Phone:910-323-5522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1753111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC013GNOtherBCBS
NC89013GNMedicaid
NCU11605Medicare UPIN
NC2447555AMedicare ID - Type Unspecified
NC37919Medicare UPIN