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General NPI Number Information
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NPI Number | 1407802986
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Entity Type | Organization
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Legal Business Name | LATE NIGHT CHIROPRACTIC PLLC
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Dates
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Enumeration Date | 05/26/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 102 W PINE ST
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City | STILWELL
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State | OK
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Zip | 74960-2652
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Country | US
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Telephone | 918-696-7220
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Fax | 918-696-7479
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Provider Business Mailing Address
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Address Line | 102 W PINE ST
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City | STILWELL
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State | OK
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Zip | 74960-2652
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Country | US
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Telephone | 918-696-7220
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Fax | 918-696-7479
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. TINA MARIE SOUTHWORTH
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Credential | DC
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Telephone | 918-696-7220
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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 | 3496
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License Number State | OK
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