Healthcare Provider Details

I. General information

NPI: 1083109037
Provider Name (Legal Business Name): PROVISION CARES PROTON CENTER OKC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 W MEMORIAL RD
OKLAHOMA CITY OK
73142-2015
US

IV. Provider business mailing address

6450 PROVISION CARES WAY
KNOXVILLE TN
37909-2544
US

V. Phone/Fax

Practice location:
  • Phone: 865-342-4518
  • Fax:
Mailing address:
  • Phone: 865-342-4518
  • Fax: 865-321-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VALERIE GIBBS
Title or Position: DIRECTOR OF BUSINESS OPERATIONS
Credential:
Phone: 865-342-4518