Healthcare Provider Details

I. General information

NPI: 1447972864
Provider Name (Legal Business Name): TOTAL ECLIPSE DMH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 S ELM PL STE C
BROKEN ARROW OK
74012-5369
US

IV. Provider business mailing address

817 S ELM PL STE C
BROKEN ARROW OK
74012-5369
US

V. Phone/Fax

Practice location:
  • Phone: 918-940-4734
  • Fax: 918-940-4737
Mailing address:
  • Phone: 918-940-4734
  • Fax: 918-940-4737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DUSTIN OLEATH HAYES
Title or Position: PHYSICIAN
Credential: DO
Phone: 469-427-9708