Provider Demographics
NPI:1902942048
Name:EITZEN CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:EITZEN CHIROPRACTIC PLLC
Other - Org Name:ADVANCED CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:EITZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:580-237-5007
Mailing Address - Street 1:523 S INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5631
Mailing Address - Country:US
Mailing Address - Phone:580-237-5007
Mailing Address - Fax:580-234-6851
Practice Address - Street 1:523 S INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5631
Practice Address - Country:US
Practice Address - Phone:580-237-5007
Practice Address - Fax:580-234-6851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3805261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK446902380001OtherBCBS PROVIDER NUMBER
OK=========OtherTAX I.D. (EIN)