Provider Demographics
NPI:1255350393
Name:CRYSTAL, KEITH BRIAN (DC)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:BRIAN
Last Name:CRYSTAL
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 1:109 MAPLE ROW BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3853
Mailing Address - Country:US
Mailing Address - Phone:615-822-1922
Mailing Address - Fax:615-822-1926
Practice Address - Street 1:109 MAPLE ROW BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-3853
Practice Address - Country:US
Practice Address - Phone:615-822-1922
Practice Address - Fax:615-822-1926
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000000762111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3675971Medicare ID - Type Unspecified
TNU22613Medicare UPIN