=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710470059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AWESOME CHIROPRACTIC CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2018
-----------------------------------------------------
Last Update Date | 06/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 COONROD AVE
-----------------------------------------------------
City | MANNFORD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74044-0063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-865-8811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 COONROD AVE
-----------------------------------------------------
City | MANNFORD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74044-0063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-865-8811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHERIDAN SCOTT RENSHAW
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 918-865-8811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4281
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------