Provider Demographics
NPI:1972781722
Name:ADVANCED CHIROPRACTIC AND REHABILITATION CLINIC P L L C
Entity type:Organization
Organization Name:ADVANCED CHIROPRACTIC AND REHABILITATION CLINIC P L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:LAYNE
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-455-7555
Mailing Address - Street 1:1712 S POST RD
Mailing Address - Street 2:STE B
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-6613
Mailing Address - Country:US
Mailing Address - Phone:405-455-7555
Mailing Address - Fax:
Practice Address - Street 1:1712 S POST RD
Practice Address - Street 2:SUITE B
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-6604
Practice Address - Country:US
Practice Address - Phone:405-455-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3870111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKB5149Medicare PIN