MEDICARE: SOUTHERN CHIRO VIDALIA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1598612228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CHIRO VIDALIA, LLC

Provider Business Mailing Address
First Line	:	116 SAVANNAH AVE
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-4801
Country	:	US
Telephone Number	:	912-243-9200
Fax Number	:	912-243-9207

Provider Business Practice Location Address
First Line	:	414 LUGENIA DR.
Second Line	:
City	:	VIDALIA
State	:	GA
Zip	:	30474
Country	:	US
Telephone Number	:	912-685-9200
Fax Number	:	912-243-9207

Authorized Official
Title or Position	:	OWNER/CHIROPRACTOR
Name	:	HORANNE CRUE
Credential	:	DC
Telephone Number	:	912-243-9200

Provider Enumeration Date	:	03/12/2026
Last Update Date	:	03/12/2026

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