Healthcare Provider Details

I. General information

NPI: 1407234693
Provider Name (Legal Business Name): BRIAN LORANCE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E. 14ST.
ADA OK
74820
US

IV. Provider business mailing address

1100 E 14TH ST
ADA OK
74820-6915
US

V. Phone/Fax

Practice location:
  • Phone: 580-559-5315
  • Fax: 580-332-8361
Mailing address:
  • Phone: 580-559-5315
  • Fax: 580-332-8361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number535
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: