MEDICARE: DR. GARRY THOMAS PAGE JR. 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	3311	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3311	OTHER	OK	LICENSE NUMBER

General Provider Information

NPI Number	:	1780688507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARRY THOMAS PAGE JR. D.C.

Provider Business Mailing Address
First Line	:	PO BOX 745
Second Line	:
City	:	FORT GIBSON
State	:	OK
Zip	:	74434-0745
Country	:	US
Telephone Number	:	918-478-3388
Fax Number	:	918-478-3397

Provider Business Practice Location Address
First Line	:	1596 S LEE ST
Second Line	:
City	:	FORT GIBSON
State	:	OK
Zip	:	74434-8403
Country	:	US
Telephone Number	:	918-478-3388
Fax Number	:	918-478-3397

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	02/03/2010

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