Provider Demographics
NPI:1740711951
Name:GO LIGHTLY CHIROPRACTIC REVOLUTION WELLNESS
Entity type:Organization
Organization Name:GO LIGHTLY CHIROPRACTIC REVOLUTION WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SETH
Authorized Official - Middle Name:CHARLES RAYE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-382-4560
Mailing Address - Street 1:205 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-4318
Mailing Address - Country:US
Mailing Address - Phone:580-382-4560
Mailing Address - Fax:
Practice Address - Street 1:205 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4318
Practice Address - Country:US
Practice Address - Phone:580-382-4560
Practice Address - Fax:580-382-4360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4211111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1477931574Medicare UPIN