Provider Demographics
NPI:1679853030
Name:MID-DEL CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:MID-DEL CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:405-601-0700
Mailing Address - Street 1:5113 SE 15TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-3952
Mailing Address - Country:US
Mailing Address - Phone:405-601-0700
Mailing Address - Fax:405-605-5776
Practice Address - Street 1:5113 SE 15TH ST STE C
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3952
Practice Address - Country:US
Practice Address - Phone:405-601-0700
Practice Address - Fax:405-605-5776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3752111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty