Healthcare Provider Details

I. General information

NPI: 1932661568
Provider Name (Legal Business Name): COHESIVE MEDIRYDE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 S STATE ST
EDMOND OK
73013-3600
US

IV. Provider business mailing address

2510 E INDEPENDENCE ST
SHAWNEE OK
74804-1839
US

V. Phone/Fax

Practice location:
  • Phone: 405-395-4474
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: BOBBY ZEIGLER
Title or Position: CREDENTIALING OPERATIONS
Credential:
Phone: 918-902-0460