Provider Demographics
NPI:1386899110
Name:CCC OF OWASSO INC
Entity type:Organization
Organization Name:CCC OF OWASSO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SWACHA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-272-8054
Mailing Address - Street 1:435 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-3208
Mailing Address - Country:US
Mailing Address - Phone:918-272-8054
Mailing Address - Fax:918-274-8044
Practice Address - Street 1:435 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-3208
Practice Address - Country:US
Practice Address - Phone:918-272-8054
Practice Address - Fax:918-274-8044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-20
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty