Provider Demographics
NPI:1104991280
Name:PRENTICE FAMILY CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:PRENTICE FAMILY CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PRENTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-296-0525
Mailing Address - Street 1:9428 S ELWOOD AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2317
Mailing Address - Country:US
Mailing Address - Phone:918-296-0525
Mailing Address - Fax:918-296-0526
Practice Address - Street 1:9428 S ELWOOD AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-2317
Practice Address - Country:US
Practice Address - Phone:918-296-0525
Practice Address - Fax:918-296-0526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3725111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK443769532002OtherBLUE CROSS BLUE SHIELD
V03642Medicare UPIN