Provider Demographics
NPI:1578281663
Name:PROACTIVE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:PROACTIVE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-801-3665
Mailing Address - Street 1:6401 N INTERSTATE DR STE 148
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-9524
Mailing Address - Country:US
Mailing Address - Phone:405-801-3665
Mailing Address - Fax:405-801-3666
Practice Address - Street 1:6401 N INTERSTATE DR STE 148
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-9524
Practice Address - Country:US
Practice Address - Phone:405-801-3665
Practice Address - Fax:405-801-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty