Healthcare Provider Details

I. General information

NPI: 1922280965
Provider Name (Legal Business Name): SUCCESS VISION EXPRESS OF TULSA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2007
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7472 E ADMIRAL PL
TULSA OK
74115-7913
US

IV. Provider business mailing address

7472 E ADMIRAL PL
TULSA OK
74115-7913
US

V. Phone/Fax

Practice location:
  • Phone: 918-834-2929
  • Fax: 918-834-4005
Mailing address:
  • Phone: 918-794-9029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2049
License Number StateOK

VIII. Authorized Official

Name: ROSE DAVYDOVA
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 918-800-2020