Provider Demographics
NPI:1174736706
Name:CROCKETT FOOT AND ANKLE CLINIC, INC.
Entity type:Organization
Organization Name:CROCKETT FOOT AND ANKLE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHADBURN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:931-766-3040
Mailing Address - Street 1:369 BRINK ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-3243
Mailing Address - Country:US
Mailing Address - Phone:931-766-3040
Mailing Address - Fax:
Practice Address - Street 1:369 BRINK ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-3243
Practice Address - Country:US
Practice Address - Phone:931-766-3040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN667213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5930140001Medicare NSC
TN3736755Medicare PIN