Provider Demographics
NPI:1598947483
Name:CORNWELL CLINIC
Entity Type:Organization
Organization Name:CORNWELL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:RONDALL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CORNWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-330-2400
Mailing Address - Street 1:285 S SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-4767
Mailing Address - Country:US
Mailing Address - Phone:405-330-2400
Mailing Address - Fax:405-330-6591
Practice Address - Street 1:285 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-4767
Practice Address - Country:US
Practice Address - Phone:405-330-2400
Practice Address - Fax:405-330-6591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3476111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty