MEDICARE: FAMILY CHIROPRACTIC P C

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	3446	OK

General Provider Information

NPI Number	:	1619092483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY CHIROPRACTIC P C

Provider Business Mailing Address
First Line	:	PO BOX 21824
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73156-1824
Country	:	US
Telephone Number	:	405-634-0042
Fax Number	:	405-632-7976

Provider Business Practice Location Address
First Line	:	8901 S SANTA FE AVE
Second Line	:	SUITE A
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-8413
Country	:	US
Telephone Number	:	405-634-0042
Fax Number	:	405-632-7976

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBYNN MICHELLE POORTVLIET
Credential	:	D.C.
Telephone Number	:	405-822-4476

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	05/05/2008

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