MEDICARE: CODY ELLEDGE D.C. PLLC

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	171100000X	Acupuncturist
2	111N00000X	Chiropractor	3835	OK

General Provider Information

NPI Number	:	1821438854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CODY ELLEDGE D.C. PLLC

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	:	405-703-3033
Fax Number	:

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	:	405-703-3033
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DR. CODY ELLEDGE
Credential	:	D.C.
Telephone Number	:	405-703-3033

Provider Enumeration Date	:	07/05/2013
Last Update Date	:	07/05/2013

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