Healthcare Provider Details

I. General information

NPI: 1508998808
Provider Name (Legal Business Name): PK XRAY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 S 37TH ST
MUSKOGEE OK
74401-4906
US

IV. Provider business mailing address

347 S 37TH ST
MUSKOGEE OK
74401-4906
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-9729
  • Fax: 918-683-1012
Mailing address:
  • Phone: 918-683-9729
  • Fax: 918-683-1012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number701503
License Number StateOK

VIII. Authorized Official

Name: MR. PHILLIP LEE KIZZIA
Title or Position: PRESIDENT
Credential:
Phone: 918-683-9729