Provider Demographics
NPI:1669508529
Name:EGLESTON, TERA MARCHELLE (DC)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:MARCHELLE
Last Name:EGLESTON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9100 N GARNETT RD
Mailing Address - Street 2:SUITE I.
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4452
Mailing Address - Country:US
Mailing Address - Phone:918-274-2911
Mailing Address - Fax:918-274-2911
Practice Address - Street 1:9100 N GARNETT RD
Practice Address - Street 2:SUITE I.
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4452
Practice Address - Country:US
Practice Address - Phone:918-274-2911
Practice Address - Fax:918-274-2911
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3469111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU73089Medicare UPIN