Healthcare Provider Details

I. General information

NPI: 1790129559
Provider Name (Legal Business Name): LTAC ASSOCIATES OF OKLAHOMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 N CLASSEN BLVD SUITE 100
OKLAHOMA CITY OK
73118-2871
US

IV. Provider business mailing address

3801 N CLASSEN BLVD SUITE 100
OKLAHOMA CITY OK
73118-2871
US

V. Phone/Fax

Practice location:
  • Phone: 405-557-1200
  • Fax: 405-557-1977
Mailing address:
  • Phone: 405-557-1200
  • Fax: 405-557-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JASON MARTIN
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 405-557-1200