Provider Demographics
NPI:1407049307
Name:JONATHAN D. WREN D.C.
Entity Type:Organization
Organization Name:JONATHAN D. WREN D.C.
Other - Org Name:MEDFORD FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WREN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:580-747-6425
Mailing Address - Street 1:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73759-0271
Mailing Address - Country:US
Mailing Address - Phone:580-747-6425
Mailing Address - Fax:
Practice Address - Street 1:104 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OK
Practice Address - Zip Code:73759-1232
Practice Address - Country:US
Practice Address - Phone:580-747-6425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3612111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK300522047Medicare PIN