Healthcare Provider Details

I. General information

NPI: 1912237751
Provider Name (Legal Business Name): JAMES KEITH CARSON CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W I 240 SERVICE RD
OKLAHOMA CITY OK
73139-7701
US

IV. Provider business mailing address

4801 S BROADWAY PL
OKLAHOMA CITY OK
73109-7524
US

V. Phone/Fax

Practice location:
  • Phone: 405-604-9644
  • Fax: 405-604-9689
Mailing address:
  • Phone: 405-631-1872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number300
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: