Provider Demographics
NPI:1174777544
Name:GRAND LAKE CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:GRAND LAKE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCHNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-786-2442
Mailing Address - Street 1:PO BOX 450638
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-0638
Mailing Address - Country:US
Mailing Address - Phone:918-786-2442
Mailing Address - Fax:918-786-2634
Practice Address - Street 1:240 E 3RD ST
Practice Address - Street 2:SUITE C
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-7072
Practice Address - Country:US
Practice Address - Phone:918-786-2442
Practice Address - Fax:918-786-2634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2575111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100724160AMedicaid
OKU46482Medicare UPIN
OK100724160AMedicaid