=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225154396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHIROPRACTIC SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 10/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 N COMMERCE ST SUITE 103
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-1438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-223-4858
-----------------------------------------------------
Fax | 580-226-6111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2400 N COMMERCE ST SUITE 103
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-1438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-223-4858
-----------------------------------------------------
Fax | 580-226-6111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE ADMINISTRTOR
-----------------------------------------------------
Name | MRS. KERRY ELLIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-223-4858
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 1596
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------