Provider Demographics
NPI:1609888775
Name:IDABEL CHIROPRACTIC CLINIC PLLC
Entity Type:Organization
Organization Name:IDABEL CHIROPRACTIC CLINIC PLLC
Other - Org Name:ENSLEY CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:ENSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:580-286-6546
Mailing Address - Street 1:1420 SE WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-3448
Mailing Address - Country:US
Mailing Address - Phone:580-286-6546
Mailing Address - Fax:
Practice Address - Street 1:1420 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-3448
Practice Address - Country:US
Practice Address - Phone:580-286-6546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3768111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKV10899Medicare UPIN
OK243700805Medicare PIN