Healthcare Provider Details

I. General information

NPI: 1972781722
Provider Name (Legal Business Name): ADVANCED CHIROPRACTIC AND REHABILITATION CLINIC P L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 05/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 S POST RD SUITE B
MIDWEST CITY OK
73130-6604
US

IV. Provider business mailing address

1712 S POST RD STE B
MIDWEST CITY OK
73130-6613
US

V. Phone/Fax

Practice location:
  • Phone: 405-455-7555
  • Fax:
Mailing address:
  • Phone: 405-455-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number3870
License Number StateOK

VIII. Authorized Official

Name: DR. JOSHUA LAYNE KOCH
Title or Position: DOCTOR OF CHIROPRACTIC
Credential: D.C.
Phone: 405-455-7555