=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841316320
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROKEN ARROW MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 12/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3023 S HARVARD AVE SUITE B
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74114-6139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-742-2094
-----------------------------------------------------
Fax | 918-742-2095
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1117
-----------------------------------------------------
City | SKIATOOK
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74070-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-742-2094
-----------------------------------------------------
Fax | 918-742-2095
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CRAIG ALAN DAY
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 918-742-2094
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2219
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------