Healthcare Provider Details

I. General information

NPI: 1114101797
Provider Name (Legal Business Name): BLANTON CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E BROADWAY AVE
PONCA CITY OK
74601-4302
US

IV. Provider business mailing address

101 E BROADWAY AVE
PONCA CITY OK
74601-4302
US

V. Phone/Fax

Practice location:
  • Phone: 580-765-2482
  • Fax: 580-765-4852
Mailing address:
  • Phone: 580-765-2482
  • Fax: 580-765-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. TIMOTHY RAY BLANTON
Title or Position: CHIROPRACTOR/OWNER
Credential: D.C.
Phone: 580-765-2482