Provider Demographics
NPI:1629827159
Name:TRISTAR SPINE AND SPORT CHIROPRACTIC LLC
Entity type:Organization
Organization Name:TRISTAR SPINE AND SPORT CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:THADDEUS
Authorized Official - Middle Name:
Authorized Official - Last Name:KEKLAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:423-360-7366
Mailing Address - Street 1:911 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-2105
Mailing Address - Country:US
Mailing Address - Phone:423-764-2663
Mailing Address - Fax:423-793-1100
Practice Address - Street 1:911 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-2105
Practice Address - Country:US
Practice Address - Phone:423-764-2663
Practice Address - Fax:423-793-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty