Healthcare Provider Details

I. General information

NPI: 1639526924
Provider Name (Legal Business Name): KEY HEALTH TULSA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5522 S LEWIS AVE SUITE 200
TULSA OK
74105-7105
US

IV. Provider business mailing address

5522 S LEWIS AVE SUITE 200
TULSA OK
74105-7105
US

V. Phone/Fax

Practice location:
  • Phone: 918-387-0700
  • Fax: 918-387-0701
Mailing address:
  • Phone: 918-387-0700
  • Fax: 918-387-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHEN WILSON
Title or Position: DIRECTOR OF KEY HEALTH TULSA
Credential: MD
Phone: 918-488-8285