Healthcare Provider Details

I. General information

NPI: 1538270954
Provider Name (Legal Business Name): ALLERGY CLINIC OF TULSA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9311 S MINGO RD
TULSA OK
74133-5702
US

IV. Provider business mailing address

9311 S MINGO RD
TULSA OK
74133-5702
US

V. Phone/Fax

Practice location:
  • Phone: 918-307-1613
  • Fax: 918-307-2454
Mailing address:
  • Phone: 918-307-1613
  • Fax: 918-307-2454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGELA THOMAS
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 918-307-1613