Healthcare Provider Details

I. General information

NPI: 1154503639
Provider Name (Legal Business Name): FAMILY WELLNESS CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 COMMONS CIR A
YUKON OK
73099
US

IV. Provider business mailing address

1809 COMMONS CIR A
YUKON OK
73099
US

V. Phone/Fax

Practice location:
  • Phone: 405-577-6268
  • Fax: 405-577-6371
Mailing address:
  • Phone: 405-577-6268
  • Fax: 405-577-6371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3850
License Number StateOK

VIII. Authorized Official

Name: JONATHAN VESTAL
Title or Position: OWNER/CHIROPRACTOR
Credential: DC
Phone: 405-577-6268