Healthcare Provider Details

I. General information

NPI: 1942239702
Provider Name (Legal Business Name): VANTAGE OPEN MRI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W HEFNER RD
OKLAHOMA CITY OK
73120-5083
US

IV. Provider business mailing address

3400 W HEFNER RD
OKLAHOMA CITY OK
73120-5083
US

V. Phone/Fax

Practice location:
  • Phone: 405-418-0900
  • Fax: 405-418-0901
Mailing address:
  • Phone: 405-418-0900
  • Fax: 405-418-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number StateOK

VIII. Authorized Official

Name: RANDY WAYNE WICKERSHAM
Title or Position: VP OF OPERATIONS
Credential:
Phone: 405-418-0900