Provider Demographics
NPI:1477559201
Name:ROADHOUSE, BRIAN (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:ROADHOUSE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6565 S YALE AVE
Mailing Address - Street 2:STE 106
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8310
Mailing Address - Country:US
Mailing Address - Phone:918-481-2770
Mailing Address - Fax:918-481-2774
Practice Address - Street 1:6565 S YALE AVE
Practice Address - Street 2:STE 106
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8310
Practice Address - Country:US
Practice Address - Phone:918-481-2770
Practice Address - Fax:918-481-2774
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2353111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT80004Medicare UPIN