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General NPI Number Information
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NPI Number | 1629237904
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Entity Type | Organization
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Legal Business Name | TTD MANAGEMENT TRUST
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Dates
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Enumeration Date | 06/03/2008
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Last Update Date | 06/03/2008
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Provider Practice Location Address
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Address Line | 901 S MAIN ST
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City | GROVE
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State | OK
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Zip | 74344-2845
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Country | US
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Telephone | 918-786-1056
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Fax |
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Provider Business Mailing Address
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Address Line | 901 S MAIN ST
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City | GROVE
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State | OK
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Zip | 74344-2845
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Country | US
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Telephone | 918-786-1056
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. SARA PENNELL
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Credential | D.C.
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Telephone | 918-786-1056
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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 | 2637
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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