Healthcare Provider Details

I. General information

NPI: 1881812618
Provider Name (Legal Business Name): TINA E TAKEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 N MERIDIAN AVE SUITE 311
OKLAHOMA CITY OK
73116-1420
US

IV. Provider business mailing address

134 NE 21ST ST
MOORE OK
73160-4410
US

V. Phone/Fax

Practice location:
  • Phone: 405-721-1115
  • Fax:
Mailing address:
  • Phone: 405-923-0069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberTA218
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: