Provider Demographics
NPI:1629237904
Name:TTD MANAGEMENT TRUST
Entity Type:Organization
Organization Name:TTD MANAGEMENT TRUST
Other - Org Name:GROVE CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-786-1056
Mailing Address - Street 1:901 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-2845
Mailing Address - Country:US
Mailing Address - Phone:918-786-1056
Mailing Address - Fax:
Practice Address - Street 1:901 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2845
Practice Address - Country:US
Practice Address - Phone:918-786-1056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2637111N00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK523663022Medicare PIN
OKU32823Medicare UPIN