=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093336448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINAL CORRECTIVE CTR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2020
-----------------------------------------------------
Last Update Date | 01/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 SUNSET DR STE 100
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-2492
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-926-8304
-----------------------------------------------------
Fax | 423-926-5976
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 SUNSET DR STE 100
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-2492
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-926-8304
-----------------------------------------------------
Fax | 423-926-5976
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CRAIG CARROLL LIVESAY
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 423-926-8304
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------