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General NPI Number Information
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NPI Number | 1063614683
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Entity Type | Organization
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Legal Business Name | PRIDEMORE FAMILY CHIROPRACTIC PC
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Dates
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Enumeration Date | 06/05/2007
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Last Update Date | 08/29/2007
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Provider Practice Location Address
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Address Line | 514 E WATAUGA AVE
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City | JOHNSON CITY
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State | TN
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Zip | 37601-4039
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Country | US
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Telephone | 423-928-4101
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Fax | 423-928-0994
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Provider Business Mailing Address
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Address Line | 514 E WATAUGA AVE
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City | JOHNSON CITY
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State | TN
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Zip | 37601-4039
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Country | US
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Telephone | 423-928-4101
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Fax | 423-928-0994
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SHAWN R PRIDEMORE
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Credential | DC
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Telephone | 423-928-4101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | DC00000001297
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License Number State | TN
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