Healthcare Provider Details

I. General information

NPI: 1124345665
Provider Name (Legal Business Name): SOUTHEASTERN OKLAHOMA SPORTS MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 04/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 N WASHINGTON AVE SUITE C
DURANT OK
74701-2100
US

IV. Provider business mailing address

1705 N WASHINGTON AVE SUITE C
DURANT OK
74701-2100
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-1414
  • Fax: 580-931-0300
Mailing address:
  • Phone: 580-924-1414
  • Fax: 580-931-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number24887
License Number StateOK

VIII. Authorized Official

Name: BRIAN K RICH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 580-924-1414