Provider Demographics
NPI:1821328915
Name:STOUT-FERGUSON CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:STOUT-FERGUSON CHIROPRACTIC, PLLC
Other - Org Name:JOE M FERGUSON DBA STOUT CLINIC OF CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CO-OWNER, MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-786-8834
Mailing Address - Street 1:1107 E 13TH ST
Mailing Address - Street 2:STE'S A&B
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-7955
Mailing Address - Country:US
Mailing Address - Phone:918-786-8834
Mailing Address - Fax:918-786-6520
Practice Address - Street 1:1107 E 13TH ST
Practice Address - Street 2:STE'S A&B
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-7955
Practice Address - Country:US
Practice Address - Phone:918-786-8834
Practice Address - Fax:918-786-6520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKA103142Medicare PIN