Healthcare Provider Details

I. General information

NPI: 1912983719
Provider Name (Legal Business Name): PONCA CITY OPEN MRI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 N 14TH ST
PONCA CITY OK
74601-1829
US

IV. Provider business mailing address

2112 N 14TH ST
PONCA CITY OK
74601-1829
US

V. Phone/Fax

Practice location:
  • Phone: 580-762-6740
  • Fax: 580-762-9627
Mailing address:
  • Phone: 580-762-6740
  • Fax: 580-762-9627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. CLINTON LOCKE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 580-762-6740