Provider Demographics
NPI:1578950952
Name:JAKE LANDRETH, DC, INC
Entity Type:Organization
Organization Name:JAKE LANDRETH, DC, INC
Other - Org Name:LANDRETH CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:LANDRETH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-521-8888
Mailing Address - Street 1:PO BOX 877
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-0877
Mailing Address - Country:US
Mailing Address - Phone:918-396-2848
Mailing Address - Fax:918-553-8802
Practice Address - Street 1:108 N. BROADWAY
Practice Address - Street 2:
Practice Address - City:SKIATOOK
Practice Address - State:OK
Practice Address - Zip Code:74070
Practice Address - Country:US
Practice Address - Phone:918-396-2848
Practice Address - Fax:318-553-8802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4002111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty