=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720640303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSIDY DO DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2019
-----------------------------------------------------
Last Update Date | 07/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 804 NE 23RD ST
-----------------------------------------------------
City | MOORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73160-8976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-794-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12205 S WESTERN AVE APT 834
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73170-5961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-826-7724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4326
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------