Provider Demographics
NPI:1174733141
Name:MEM III INCORPORATED
Entity type:Organization
Organization Name:MEM III INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:918-437-5355
Mailing Address - Street 1:12502 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-1803
Mailing Address - Country:US
Mailing Address - Phone:918-437-5355
Mailing Address - Fax:918-437-5356
Practice Address - Street 1:12502 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-1803
Practice Address - Country:US
Practice Address - Phone:918-437-5355
Practice Address - Fax:918-437-5356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2021-11-17
Deactivation Date:2021-09-22
Deactivation Code:
Reactivation Date:2021-11-17
Provider Licenses
StateLicense IDTaxonomies
OK2499111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
352609309-002OtherBLUE CROSS BLUE SHEILD
OK352609309Medicare ID - Type Unspecified
352609309-002OtherBLUE CROSS BLUE SHEILD