Provider Demographics
NPI:1073732087
Name:IMPACT CHIROPRACTIC CLINIC INC PC
Entity Type:Organization
Organization Name:IMPACT CHIROPRACTIC CLINIC INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEHNHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-893-6400
Mailing Address - Street 1:4705 W URBANA
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5998
Mailing Address - Country:US
Mailing Address - Phone:918-893-6400
Mailing Address - Fax:918-893-6402
Practice Address - Street 1:4705 W URBANA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5998
Practice Address - Country:US
Practice Address - Phone:918-893-6400
Practice Address - Fax:918-893-6402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2589111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty