MEDICARE: STANDRIDGE CLINIC INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NR0400X	Rehabilitation Chiropractor	2448	OK

General Provider Information

NPI Number	:	1033271655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STANDRIDGE CLINIC INC

Provider Business Mailing Address
First Line	:	12707 E. 86TH ST. N.
Second Line	:
City	:	OWASSO
State	:	OK
Zip	:	74055
Country	:	US
Telephone Number	:	918-272-7432
Fax Number	:	918-272-7448

Provider Business Practice Location Address
First Line	:	12707 E 86TH ST N
Second Line	:
City	:	OWASSO
State	:	OK
Zip	:	74055-2506
Country	:	US
Telephone Number	:	918-272-7432
Fax Number	:	918-272-7448

Authorized Official
Title or Position	:	OWNER
Name	:	TRACY L STANDRIDGE
Credential	:	D.C.
Telephone Number	:	918-272-7432

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	03/29/2010

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