Healthcare Provider Details

I. General information

NPI: 1427960467
Provider Name (Legal Business Name): SERVANT SPINE CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 SW 30TH CT STE B
MOORE OK
73160-2887
US

IV. Provider business mailing address

1101 SW 30TH CT STE B
MOORE OK
73160-2887
US

V. Phone/Fax

Practice location:
  • Phone: 405-727-5263
  • Fax:
Mailing address:
  • Phone: 405-727-5263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. CALEB WALLACE
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 405-727-5263