Healthcare Provider Details

I. General information

NPI: 1871249631
Provider Name (Legal Business Name): ATHLETICO LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 S WESTERN AVE STE A3
OKLAHOMA CITY OK
73170-6085
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 405-200-1869
  • Fax: 405-200-1873
Mailing address:
  • Phone: 630-575-1980
  • Fax: 630-928-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JUANA GRANADOS
Title or Position: DIRECTOR, CREDENTIALING
Credential:
Phone: 630-575-1980