=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043764533
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRADDY CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2016
-----------------------------------------------------
Last Update Date | 08/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3315 E 47TH PL STE. 120
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74135-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-622-9655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12410 E 128TH PL N
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74021-7182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-378-9801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/OWNER
-----------------------------------------------------
Name | DR. CHRISTINA MARIE GRADDY
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 918-378-9801
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3866
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------