Provider Demographics
NPI:1518465988
Name:AGAPE CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:AGAPE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:BRACKELSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-888-6543
Mailing Address - Street 1:2716 SWEETBRIAR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6569
Mailing Address - Country:US
Mailing Address - Phone:405-888-6543
Mailing Address - Fax:
Practice Address - Street 1:3709 E 2ND ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034
Practice Address - Country:US
Practice Address - Phone:405-888-6543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4268111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty