Provider Demographics
NPI:1871907634
Name:SOONER CHIROPRACTIC, PLLC
Entity type:Organization
Organization Name:SOONER CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:KRISTOPHER
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-285-0300
Mailing Address - Street 1:13612 BELL AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-5915
Mailing Address - Country:US
Mailing Address - Phone:405-285-0300
Mailing Address - Fax:405-285-0455
Practice Address - Street 1:788 N SANTA FE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-4300
Practice Address - Country:US
Practice Address - Phone:405-285-0300
Practice Address - Fax:405-285-0455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3391111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK245602301Medicare PIN