Healthcare Provider Details

I. General information

NPI: 1740722115
Provider Name (Legal Business Name): GREEN COUNTRY PAIN MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6048-A S SHERIDAN RD
TULSA OK
74145
US

IV. Provider business mailing address

6048-A S SHERIDAN RD
TULSA OK
74145
US

V. Phone/Fax

Practice location:
  • Phone: 918-935-3240
  • Fax: 918-935-3241
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: LESLIE CHAN
Title or Position: SOLE MEMBER
Credential: MD
Phone: 918-935-3240