Provider Demographics
NPI:1164615407
Name:PEACE CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:PEACE CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:PEACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-747-2717
Mailing Address - Street 1:4134 S HARVARD AVE STE B2
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2613
Mailing Address - Country:US
Mailing Address - Phone:917-747-2717
Mailing Address - Fax:918-747-2718
Practice Address - Street 1:4134 S HARVARD AVE
Practice Address - Street 2:STE B2
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2628
Practice Address - Country:US
Practice Address - Phone:917-747-2717
Practice Address - Fax:918-747-2718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3461111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK300522154Medicare PIN