Healthcare Provider Details

I. General information

NPI: 1720671688
Provider Name (Legal Business Name): OKC MEDICAL STOP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10717 N MAY AVE
OKLAHOMA CITY OK
73120-2620
US

IV. Provider business mailing address

10717 N MAY AVE
OKLAHOMA CITY OK
73120-2620
US

V. Phone/Fax

Practice location:
  • Phone: 405-625-2024
  • Fax:
Mailing address:
  • Phone: 405-625-2024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JACK SULLIVAN
Title or Position: OWNER
Credential:
Phone: 405-625-2024