Provider Demographics
NPI:1528289329
Name:ARDMORE CHIROPRACTIC CLINIC, INC.
Entity type:Organization
Organization Name:ARDMORE CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:580-223-8200
Mailing Address - Street 1:1702 N COMMERCE ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1525
Mailing Address - Country:US
Mailing Address - Phone:580-223-8200
Mailing Address - Fax:580-223-8212
Practice Address - Street 1:1702 N COMMERCE ST
Practice Address - Street 2:SUITE E
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1525
Practice Address - Country:US
Practice Address - Phone:580-223-8200
Practice Address - Fax:580-223-8212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200096760AMedicaid
OK800522128Medicare ID - Type Unspecified
OK200096760AMedicaid
OK5240880001Medicare NSC