Provider Demographics
NPI:1578748133
Name:SPINAL DECOMPRESSION CENTER OF TULSA, LLC
Entity Type:Organization
Organization Name:SPINAL DECOMPRESSION CENTER OF TULSA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-481-0655
Mailing Address - Street 1:6951 E 71ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-2757
Mailing Address - Country:US
Mailing Address - Phone:918-481-0655
Mailing Address - Fax:918-481-8729
Practice Address - Street 1:6951 E 71ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-2757
Practice Address - Country:US
Practice Address - Phone:918-481-0655
Practice Address - Fax:918-481-8729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK444-68-2785Medicare PIN