Healthcare Provider Details

I. General information

NPI: 1780054627
Provider Name (Legal Business Name): PMO MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W QUEENS ST SUITE 100
BROKEN ARROW OK
74012-1784
US

IV. Provider business mailing address

701 W QUEENS ST
BROKEN ARROW OK
74012-1784
US

V. Phone/Fax

Practice location:
  • Phone: 918-519-5717
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number3924
License Number StateOK

VIII. Authorized Official

Name: JEFF HALFORD
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 918-794-6008