Healthcare Provider Details

I. General information

NPI: 1114050374
Provider Name (Legal Business Name): WILBURTON FAMILY CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 02/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W MAIN ST
WILBURTON OK
74578-4046
US

IV. Provider business mailing address

208 W MAIN ST
WILBURTON OK
74578-4046
US

V. Phone/Fax

Practice location:
  • Phone: 918-465-5661
  • Fax:
Mailing address:
  • Phone: 918-465-5661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3113
License Number StateOK

VIII. Authorized Official

Name: DR. RICHARD E INGRAM
Title or Position: OWNER
Credential: D.C.
Phone: 918-465-5661