Provider Demographics
NPI:1649588096
Name:CHIROPRACTIC HEALTH CLINIC
Entity Type:Organization
Organization Name:CHIROPRACTIC HEALTH CLINIC
Other - Org Name:DICKERSON CHIROPRACTIC CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-273-6822
Mailing Address - Street 1:3705 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-2223
Mailing Address - Country:US
Mailing Address - Phone:405-273-6822
Mailing Address - Fax:888-413-2901
Practice Address - Street 1:3705 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2223
Practice Address - Country:US
Practice Address - Phone:405-273-6822
Practice Address - Fax:888-413-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4127111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK400697Medicare PIN