Healthcare Provider Details

I. General information

NPI: 1770906505
Provider Name (Legal Business Name): LELAND BOWIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 NW 39TH STREET STE 103
OKLAHOMA CITY OK
73112-0000
US

IV. Provider business mailing address

2401 NW 39TH STREET STE 103
OKLAHOMA CITY OK
73112-0000
US

V. Phone/Fax

Practice location:
  • Phone: 405-588-7641
  • Fax: 405-601-9668
Mailing address:
  • Phone: 405-588-7641
  • Fax: 405-601-9668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number303756
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: