Healthcare Provider Details

I. General information

NPI: 1972698306
Provider Name (Legal Business Name): BREAST MRI OF OKLAHOMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MCAULEY BLVD
OKLAHOMA CITY OK
73120-8302
US

IV. Provider business mailing address

PO BOX 108809
OKLAHOMA CITY OK
73101-8809
US

V. Phone/Fax

Practice location:
  • Phone: 405-749-7077
  • Fax: 405-631-9315
Mailing address:
  • Phone: 405-632-2323
  • Fax: 405-631-9315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number StateOK

VIII. Authorized Official

Name: CHARLES BREKKE
Title or Position: MANAGER
Credential: M.D.
Phone: 405-632-2323