=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194243568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NIGHTENGALE CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2017
-----------------------------------------------------
Last Update Date | 09/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2616 COVELL VILLAGE DR STE. 120
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-323-3373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 30225
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-323-3373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DEVIN LEE NIGHTENGLAE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 405-323-3373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3897
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------