Healthcare Provider Details

I. General information

NPI: 1972851467
Provider Name (Legal Business Name): INGRAM CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 N MERIDIAN AVE
OKLAHOMA CITY OK
73116-1420
US

IV. Provider business mailing address

6525 N MERIDIAN AVE
OKLAHOMA CITY OK
73116-1420
US

V. Phone/Fax

Practice location:
  • Phone: 405-719-3905
  • Fax:
Mailing address:
  • Phone: 405-719-3905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number8457
License Number StateOK

VIII. Authorized Official

Name: RICHARD ROSS
Title or Position: CEO
Credential:
Phone: 405-719-3905