=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609888775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDABEL CHIROPRACTIC CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2006
-----------------------------------------------------
Last Update Date | 04/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 SE WASHINGTON ST
-----------------------------------------------------
City | IDABEL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74745-3448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-286-6546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1420 SE WASHINGTON ST
-----------------------------------------------------
City | IDABEL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74745-3448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-286-6546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | DR. ERIC L ENSLEY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 580-286-6546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3768
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------