Provider Demographics
NPI:1649484650
Name:FOUNTAIN CITY CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:FOUNTAIN CITY CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CAWRSE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:865-688-1101
Mailing Address - Street 1:305 HOTEL RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-3229
Mailing Address - Country:US
Mailing Address - Phone:865-688-1101
Mailing Address - Fax:865-688-1109
Practice Address - Street 1:305 HOTEL RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-3229
Practice Address - Country:US
Practice Address - Phone:865-688-1101
Practice Address - Fax:865-688-1109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN194111N00000X
TN186111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2007703OtherBLUE CROSS BLUE SHIELD
TN2009917OtherBLUE CROSS BLUE SHIELD
TNT74806Medicare UPIN
TNT74807Medicare UPIN
TN3671654Medicare ID - Type UnspecifiedINDIVIDUAL
TN3671663Medicare ID - Type UnspecifiedINDIVIDUAL