Provider Demographics
NPI:1508965252
Name:TERA EGLESTON CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:TERA EGLESTON CHIROPRACTIC CLINIC PC
Other - Org Name:TERA M EGLESTON DC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERA
Authorized Official - Middle Name:MARCHELLE
Authorized Official - Last Name:EGLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-274-2911
Mailing Address - Street 1:PO BOX 1161
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055
Mailing Address - Country:US
Mailing Address - Phone:918-274-2911
Mailing Address - Fax:918-274-2911
Practice Address - Street 1:9100 N GARNETT RD
Practice Address - Street 2:SUITE I
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055
Practice Address - Country:US
Practice Address - Phone:918-274-2911
Practice Address - Fax:918-274-2911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3469111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK446821654002OtherBCBS
OK446821654002OtherBCBS