Healthcare Provider Details

I. General information

NPI: 1639604101
Provider Name (Legal Business Name): PARADIGM HORMONES -EDMOND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2017
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S I 35 SERVICE RD STE 106
MOORE OK
73160-3182
US

IV. Provider business mailing address

13100 N WESTERN AVE
OKLAHOMA CITY OK
73114-1430
US

V. Phone/Fax

Practice location:
  • Phone: 405-703-3614
  • Fax: 405-703-7021
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateOK

VIII. Authorized Official

Name: NIKKI BUSELLATO
Title or Position: INS.CREDENTIALING
Credential:
Phone: 405-703-3614