Provider Demographics
NPI:1427275007
Name:ADVANCE BACK CARE CHIROPRACTIC, PLC
Entity type:Organization
Organization Name:ADVANCE BACK CARE CHIROPRACTIC, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIPE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-341-7473
Mailing Address - Street 1:1705 W 33RD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013
Mailing Address - Country:US
Mailing Address - Phone:405-341-7473
Mailing Address - Fax:405-341-7463
Practice Address - Street 1:1705 W 33RD ST
Practice Address - Street 2:SUITE A
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-341-7473
Practice Address - Fax:405-341-7463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3683111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1740343136OtherPERSONAL NPI NUMBER
OK100522095Medicare ID - Type Unspecified