Provider Demographics
NPI:1033521430
Name:THE BACK STOP LLC
Entity type:Organization
Organization Name:THE BACK STOP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIMBLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:405-265-3920
Mailing Address - Street 1:373 S YUKON PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-4597
Mailing Address - Country:US
Mailing Address - Phone:405-265-3920
Mailing Address - Fax:405-265-3922
Practice Address - Street 1:373 S YUKON PKWY STE C
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-4597
Practice Address - Country:US
Practice Address - Phone:405-265-3920
Practice Address - Fax:405-265-3922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4154261QH0100X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service