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General NPI Number Information
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NPI Number | 1629328521
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Entity Type | Individual
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Provider Name | MYRANDA SHALANE GOLLA D.C.
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Gender | Female
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Dates
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Enumeration Date | 09/18/2012
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Last Update Date | 06/07/2024
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Provider Practice Location Address
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Address Line | 529 S 3RD ST
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City | MCALESTER
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State | OK
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Zip | 74501-5819
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Country | US
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Telephone | 918-423-4100
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3094
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City | MCALESTER
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State | OK
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Zip | 74502-3094
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Country | US
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Telephone | 918-916-0444
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 4075
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License Number State | OK
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