=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346538857
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON WILBANKS D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2011
-----------------------------------------------------
Last Update Date | 07/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3820 E 51ST ST SUITE A
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74135-3627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-747-3939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8205 E REGAL CT STE 106
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74133-7183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-747-3939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4035
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------