Provider Demographics
NPI:1083808414
Name:CHIROPRACTIC WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:CHIROPRACTIC WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOOSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-742-0560
Mailing Address - Street 1:2442 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-1749
Mailing Address - Country:US
Mailing Address - Phone:918-742-0560
Mailing Address - Fax:918-742-0605
Practice Address - Street 1:2442 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-1749
Practice Address - Country:US
Practice Address - Phone:918-742-0560
Practice Address - Fax:918-742-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3417111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00265256OtherRAILROAD MEDICARE
OK=========001OtherBLUE CROSS
OKP00265256OtherRAILROAD MEDICARE
OKOKA100463Medicare PIN