=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326155078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSSROADS FAMILY CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2006
-----------------------------------------------------
Last Update Date | 10/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58 OLD ROBERTS RD
-----------------------------------------------------
City | BENSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27504-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-989-1888
-----------------------------------------------------
Fax | 919-989-1898
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 58 OLD ROBERTS RD
-----------------------------------------------------
City | BENSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27504-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-989-1888
-----------------------------------------------------
Fax | 919-989-1898
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RYAN LEE WILLIAMS
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 919-989-1888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3387
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------