Provider Demographics
NPI:1093037046
Name:415 MAIN LLC
Entity Type:Organization
Organization Name:415 MAIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-664-7622
Mailing Address - Street 1:10317 GREENBRIAR PKWY
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7648
Mailing Address - Country:US
Mailing Address - Phone:405-378-3400
Mailing Address - Fax:866-323-7959
Practice Address - Street 1:10317 GREENBRIAR PKWY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7648
Practice Address - Country:US
Practice Address - Phone:405-378-3400
Practice Address - Fax:866-323-7959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3509111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty