MEDICARE: DR. CODY T ELLEDGE D.C.

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	3835	OK

General Provider Information

NPI Number	:	1639372956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CODY T ELLEDGE D.C.

Provider Business Mailing Address
First Line	:	5715 N WESTERN AVE STE B
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-1239
Country	:	US
Telephone Number	:	405-858-2225
Fax Number	:	405-843-0035

Provider Business Practice Location Address
First Line	:	5715 N WESTERN AVE STE B
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-1239
Country	:	US
Telephone Number	:	405-858-2225
Fax Number	:	405-858-0035

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2007
Last Update Date	:	06/28/2013

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