Healthcare Provider Details

I. General information

NPI: 1033271655
Provider Name (Legal Business Name): STANDRIDGE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12707 E 86TH ST N
OWASSO OK
74055-2506
US

IV. Provider business mailing address

12707 E. 86TH ST. N.
OWASSO OK
74055
US

V. Phone/Fax

Practice location:
  • Phone: 918-272-7432
  • Fax: 918-272-7448
Mailing address:
  • Phone: 918-272-7432
  • Fax: 918-272-7448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number2448
License Number StateOK

VIII. Authorized Official

Name: TRACY L STANDRIDGE
Title or Position: OWNER
Credential: D.C.
Phone: 918-272-7432