Healthcare Provider Details

I. General information

NPI: 1407060486
Provider Name (Legal Business Name): FENELL HAND & FOOT CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 09/06/2023
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 E 31ST STREET B
TULSA OK
74135-3512
US

IV. Provider business mailing address

3515 E 31ST STREET B
TULSA OK
74135
US

V. Phone/Fax

Practice location:
  • Phone: 918-749-4263
  • Fax: 888-505-9606
Mailing address:
  • Phone: 918-749-4263
  • Fax: 888-505-9606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3398
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. DEREK DURRELL COFFMAN
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 918-749-4263