Provider Demographics
NPI:1437475282
Name:CCM CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:CCM CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:918-479-2827
Mailing Address - Street 1:PO BOX 1471
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74352-1471
Mailing Address - Country:US
Mailing Address - Phone:918-479-2827
Mailing Address - Fax:
Practice Address - Street 1:413 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:OK
Practice Address - Zip Code:74352
Practice Address - Country:US
Practice Address - Phone:918-479-2827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3649111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty