Healthcare Provider Details

I. General information

NPI: 1639479348
Provider Name (Legal Business Name): MILESTONE PEDIATRIC CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3863 S 103RD EAST AVE
TULSA OK
74146-2443
US

IV. Provider business mailing address

3845 S 103RD EAST AVE SUITE 102
TULSA OK
74146-2452
US

V. Phone/Fax

Practice location:
  • Phone: 918-745-0800
  • Fax: 918-745-0028
Mailing address:
  • Phone: 918-745-0800
  • Fax: 918-745-0028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4195
License Number StateOK

VIII. Authorized Official

Name: DR. JAMES AARON HENLEY
Title or Position: MANAGER/MEMBER
Credential: D.O.
Phone: 918-745-0800