Provider Demographics
NPI:1578338661
Name:SHAWNEE SPINE
Entity Type:Organization
Organization Name:SHAWNEE SPINE
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:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-567-7716
Mailing Address - Street 1:407 N JIM THORPE BLVD
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864-4563
Mailing Address - Country:US
Mailing Address - Phone:405-567-7716
Mailing Address - Fax:
Practice Address - Street 1:1049 VISION BLVD STE 700
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1221
Practice Address - Country:US
Practice Address - Phone:405-567-7716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Single Specialty