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General NPI Number Information
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NPI Number | 1174714877
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Entity Type | Organization
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Legal Business Name | CENTRAL OKLAHOMA CHIROPRACTIC CLINIC INC
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Dates
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Enumeration Date | 08/07/2007
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Last Update Date | 07/24/2012
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Provider Practice Location Address
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Address Line | 602 N BROADWAY ST
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City | TECUMSEH
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State | OK
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Zip | 74873-2020
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Country | US
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Telephone | 405-598-6768
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Fax | 405-597-6770
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Provider Business Mailing Address
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Address Line | 602 N BROADWAY ST PO BOX 589
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City | TECUMSEH
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State | OK
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Zip | 74873-2020
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Country | US
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Telephone | 405-598-6768
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Fax | 405-597-6770
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JUSTIN RAY PHILLIPS
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Credential | DC
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Telephone | 405-598-6768
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 3465
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License Number State | OK
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