Provider Demographics
NPI:1912191503
Name:GRAN MIRACLE CHIROPRACTIC INC PC
Entity Type:Organization
Organization Name:GRAN MIRACLE CHIROPRACTIC INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:MIRACLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-748-9876
Mailing Address - Street 1:3515 E 31ST ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-1520
Mailing Address - Country:US
Mailing Address - Phone:918-748-9876
Mailing Address - Fax:918-748-9331
Practice Address - Street 1:3515 E 31ST ST
Practice Address - Street 2:SUITE C
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-1520
Practice Address - Country:US
Practice Address - Phone:918-748-9876
Practice Address - Fax:918-748-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2476111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty