Healthcare Provider Details

I. General information

NPI: 1740177401
Provider Name (Legal Business Name): STATE OF OKLAHOMA MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PARK AVE STE 1300
OKLAHOMA CITY OK
73102-7216
US

IV. Provider business mailing address

4570 S EASTERN AVE STE 28
LAS VEGAS NV
89119-6183
US

V. Phone/Fax

Practice location:
  • Phone: 510-456-8143
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: CRISTINE HERNANDEZ
Title or Position: CEO
Credential:
Phone: 510-456-8143