Healthcare Provider Details

I. General information

NPI: 1932750080
Provider Name (Legal Business Name): MCKENZIE BLAKE GREENWOOD ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 W BROOKS ST
NORMAN OK
73019-1018
US

IV. Provider business mailing address

180 W BROOKS ST
NORMAN OK
73019-1018
US

V. Phone/Fax

Practice location:
  • Phone: 405-659-7754
  • Fax: 405-325-8388
Mailing address:
  • Phone: 405-659-7754
  • Fax: 405-325-8388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1057
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: