Provider Demographics
NPI:1326225681
Name:ELLEDGE CHIROPRACTIC CLINIC PLLC
Entity Type:Organization
Organization Name:ELLEDGE CHIROPRACTIC CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CODY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:ELLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-703-3033
Mailing Address - Street 1:10403 S PENN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6926
Mailing Address - Country:US
Mailing Address - Phone:405-735-9495
Mailing Address - Fax:
Practice Address - Street 1:10403 S PENN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6926
Practice Address - Country:US
Practice Address - Phone:405-735-9495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3835111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty