Provider Demographics
NPI:1427238864
Name:DECLUE MEDICAL, LLC
Entity type:Organization
Organization Name:DECLUE MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DECLUE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-396-3777
Mailing Address - Street 1:208 BULLDOG BLVD
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-1073
Mailing Address - Country:US
Mailing Address - Phone:918-396-3777
Mailing Address - Fax:918-396-3066
Practice Address - Street 1:208 BULLDOG BLVD
Practice Address - Street 2:
Practice Address - City:SKIATOOK
Practice Address - State:OK
Practice Address - Zip Code:74070-1073
Practice Address - Country:US
Practice Address - Phone:918-396-3777
Practice Address - Fax:918-396-3066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2640111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK243415300Medicare PIN