Healthcare Provider Details

I. General information

NPI: 1053641803
Provider Name (Legal Business Name): MIRAWORX OF OKC 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

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

10400 VINEYARD BLVD APT A
OKLAHOMA CITY OK
73120-3830
US

IV. Provider business mailing address

10400 VINEYARD BLVD APT A
OKLAHOMA CITY OK
73120-3830
US

V. Phone/Fax

Practice location:
  • Phone: 405-230-1102
  • Fax:
Mailing address:
  • Phone: 405-230-1102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CAROLYN CUMMINS DAVIES
Title or Position: CONSULTANT
Credential: CPA
Phone: 918-286-7347