Healthcare Provider Details

I. General information

NPI: 1780018465
Provider Name (Legal Business Name): COSMETIC CENTER OF TULSA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9906 RIVERSIDE PKWY
TULSA OK
74137-7409
US

IV. Provider business mailing address

9906 RIVERSIDE PKWY
TULSA OK
74137-7409
US

V. Phone/Fax

Practice location:
  • Phone: 918-298-8080
  • Fax: 918-528-3841
Mailing address:
  • Phone: 918-298-8080
  • Fax: 918-528-3841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4362
License Number StateOK

VIII. Authorized Official

Name: JENNIFER A CUSHMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 918-298-8080