Healthcare Provider Details

I. General information

NPI: 1578748133
Provider Name (Legal Business Name): SPINAL DECOMPRESSION CENTER OF TULSA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6951 E 71ST ST
TULSA OK
74133-2757
US

IV. Provider business mailing address

6951 E 71ST ST
TULSA OK
74133-2757
US

V. Phone/Fax

Practice location:
  • Phone: 918-481-0655
  • Fax: 918-481-8729
Mailing address:
  • Phone: 918-481-0655
  • Fax: 918-481-8729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL LEE PETERSON
Title or Position: CHIROPRACTOR
Credential: D.O.
Phone: 918-481-0655