=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215122387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CUMULATIVE TRAUMA TREATMENT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2007
-----------------------------------------------------
Last Update Date | 02/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13316 S WESTERN AVE SUITE Q
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73170-7302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-703-4550
-----------------------------------------------------
Fax | 405-703-4552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13316 S WESTERN AVE SUITE Q
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73170-7302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-703-4550
-----------------------------------------------------
Fax | 405-703-4552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAY MICHAEL ADAMS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 405-703-4550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3490
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------