Provider Demographics
NPI:1407802986
Name:LATE NIGHT CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:LATE NIGHT CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SOUTHWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-696-7220
Mailing Address - Street 1:102 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-2652
Mailing Address - Country:US
Mailing Address - Phone:918-696-7220
Mailing Address - Fax:918-696-7479
Practice Address - Street 1:102 W PINE ST
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-2652
Practice Address - Country:US
Practice Address - Phone:918-696-7220
Practice Address - Fax:918-696-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3496111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK432252376001Medicare UPIN