Provider Demographics
NPI:1114101797
Name:BLANTON CLINIC
Entity type:Organization
Organization Name:BLANTON CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:580-765-2482
Mailing Address - Street 1:101 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-4302
Mailing Address - Country:US
Mailing Address - Phone:580-765-2482
Mailing Address - Fax:580-765-4852
Practice Address - Street 1:101 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4302
Practice Address - Country:US
Practice Address - Phone:580-765-2482
Practice Address - Fax:580-765-4852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty