Provider Demographics
NPI:1184170060
Name:LUMOS INNATE CENTERED CHIROPRACTIC
Entity type:Organization
Organization Name:LUMOS INNATE CENTERED CHIROPRACTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FALLON
Authorized Official - Middle Name:LACHERIA
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-960-0826
Mailing Address - Street 1:7171 S BRADEN AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6302
Mailing Address - Country:US
Mailing Address - Phone:918-960-0826
Mailing Address - Fax:539-664-9563
Practice Address - Street 1:7171 S BRADEN AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6302
Practice Address - Country:US
Practice Address - Phone:918-960-0826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4219111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty