MEDICARE: PROACTIVE SPORT AND SPINE PLC

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	111N00000X	Chiropractor	3846	OK

General Provider Information

NPI Number	:	1114260593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROACTIVE SPORT AND SPINE PLC

Provider Business Mailing Address
First Line	:	4412 W HOUSTON
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012
Country	:	US
Telephone Number	:	918-254-8700
Fax Number	:	918-254-8711

Provider Business Practice Location Address
First Line	:	4412 W HOUSTON ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-4645
Country	:	US
Telephone Number	:	918-254-8700
Fax Number	:	918-254-8711

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. TRAVIS J DEARMON
Credential	:	D.C.
Telephone Number	:	918-254-8700

Provider Enumeration Date	:	04/03/2013
Last Update Date	:	04/03/2013

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