Healthcare Provider Details

I. General information

NPI: 1972012722
Provider Name (Legal Business Name): SHOOLIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S BRYANT AVE STE 101
EDMOND OK
73034-6330
US

IV. Provider business mailing address

PO BOX 8350
EDMOND OK
73083-8350
US

V. Phone/Fax

Practice location:
  • Phone: 405-861-0004
  • Fax: 855-680-8890
Mailing address:
  • Phone: 405-861-0004
  • Fax: 855-680-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number27981
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number27981
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number27981
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number27981
License Number StateOK

VIII. Authorized Official

Name: RAKESH SHRIVASTAVA
Title or Position: OWNER
Credential: MD
Phone: 405-642-8613