Provider Demographics
NPI:1598032963
Name:THREE WAY MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:THREE WAY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:TEDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:731-784-0042
Mailing Address - Street 1:400 US HIGHWAY 45 W
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-8503
Mailing Address - Country:US
Mailing Address - Phone:731-784-0042
Mailing Address - Fax:731-784-8868
Practice Address - Street 1:400 US HIGHWAY 45 W
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-8503
Practice Address - Country:US
Practice Address - Phone:731-784-0042
Practice Address - Fax:731-784-8868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-29
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000000708111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3675375Medicare PIN