Healthcare Provider Details

I. General information

NPI: 1881887214
Provider Name (Legal Business Name): SKIATOOK MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S HOMINY AVE
SKIATOOK OK
74070-3975
US

IV. Provider business mailing address

203 S HOMINY AVE
SKIATOOK OK
74070-3975
US

V. Phone/Fax

Practice location:
  • Phone: 918-396-9000
  • Fax: 918-396-0119
Mailing address:
  • Phone: 918-396-9000
  • Fax: 918-396-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3150
License Number StateOK

VIII. Authorized Official

Name: DR. ROBERT LEE JOHNSON
Title or Position: MANAGER
Credential: DC
Phone: 918-396-9000