Provider Demographics
NPI:1184798050
Name:STANDRIDGE, TRACY L (DC)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:L
Last Name:STANDRIDGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12707 EAST 86TH STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055
Mailing Address - Country:US
Mailing Address - Phone:918-272-7432
Mailing Address - Fax:918-272-7448
Practice Address - Street 1:12707 EAST 86TH STREET NORTH
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055
Practice Address - Country:US
Practice Address - Phone:918-272-7432
Practice Address - Fax:918-272-7448
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2448111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK440560633Medicare ID - Type Unspecified