Healthcare Provider Details

I. General information

NPI: 1760644587
Provider Name (Legal Business Name): SOUTH TULSA RT ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2408 E 81ST ST STE 110
TULSA OK
74137-4215
US

IV. Provider business mailing address

11101 HEFNER POINTE DR #224
OKLAHOMA CITY OK
73120-5054
US

V. Phone/Fax

Practice location:
  • Phone: 918-388-2300
  • Fax: 918-388-2301
Mailing address:
  • Phone: 405-418-2200
  • Fax: 405-418-2201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DEREK M PRENTICE
Title or Position: MANAGING MEMBER
Credential:
Phone: 405-418-2200