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General NPI Number Information
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NPI Number | 1942586706
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Entity Type | Organization
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Legal Business Name | GREEN COUNTRY SPINE & SPORT, PLLC
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Dates
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Enumeration Date | 10/25/2011
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Last Update Date | 08/27/2013
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Provider Practice Location Address
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Address Line | 803 N FOREMAN ST
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City | VINITA
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State | OK
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Zip | 74301-1435
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Country | US
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Telephone | 918-256-5111
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Fax | 918-256-5222
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Provider Business Mailing Address
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Address Line | PO BOX 248
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City | VINITA
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State | OK
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Zip | 74301-0248
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Country | US
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Telephone | 918-256-5111
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Fax | 918-256-5222
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOSEPH CLARK
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Credential | DC
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Telephone | 918-256-5111
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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 | 4016
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License Number State | OK
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