Healthcare Provider Details

I. General information

NPI: 1821438854
Provider Name (Legal Business Name): CODY ELLEDGE D.C. PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5715 N WESTERN AVE STE B
OKLAHOMA CITY OK
73118-1239
US

IV. Provider business mailing address

5715 N WESTERN AVE STE B
OKLAHOMA CITY OK
73118-1239
US

V. Phone/Fax

Practice location:
  • Phone: 405-703-3033
  • Fax:
Mailing address:
  • Phone: 405-703-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3835
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: DR. CODY ELLEDGE
Title or Position: SOLE MEMBER
Credential: D.C.
Phone: 405-703-3033