Provider Demographics
NPI:1881002087
Name:BLACKWELL FAMILY CHIROPRACTIC INC PC
Entity Type:Organization
Organization Name:BLACKWELL FAMILY CHIROPRACTIC INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KAHLE
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:580-363-0084
Mailing Address - Street 1:1312 W DOOLIN AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74631-1357
Mailing Address - Country:US
Mailing Address - Phone:580-363-0084
Mailing Address - Fax:580-363-0079
Practice Address - Street 1:1312 W DOOLIN AVE
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631-1357
Practice Address - Country:US
Practice Address - Phone:580-363-0084
Practice Address - Fax:580-363-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKV04712Medicare UPIN