Provider Demographics
NPI:1932106820
Name:BLACKWELDER, DALE WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:WAYNE
Last Name:BLACKWELDER
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:P O BOX 785
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372
Mailing Address - Country:US
Mailing Address - Phone:731-925-2225
Mailing Address - Fax:731-925-2226
Practice Address - Street 1:635 WATER ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-2442
Practice Address - Country:US
Practice Address - Phone:731-925-2225
Practice Address - Fax:731-925-2226
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC001075111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU45429Medicare UPIN
TN36769161Medicaid
TN36769161Medicare PIN