Healthcare Provider Details

I. General information

NPI: 1710277207
Provider Name (Legal Business Name): OKLAHOMA PAIN & REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 S COLUMBIA AVE SUITE 501
TULSA OK
74114-3505
US

IV. Provider business mailing address

2121 S COLUMBIA AVE SUITE 501
TULSA OK
74114-3505
US

V. Phone/Fax

Practice location:
  • Phone: 918-747-0716
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM RYAN
Title or Position: OWNER
Credential:
Phone: 405-926-7926