Healthcare Provider Details

I. General information

NPI: 1831823939
Provider Name (Legal Business Name): TULSA VARICOSE VEIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 S YALE AVE STE 104
TULSA OK
74136-8302
US

IV. Provider business mailing address

6565 S YALE AVE STE 104
TULSA OK
74136-8302
US

V. Phone/Fax

Practice location:
  • Phone: 918-481-2773
  • Fax: 918-481-2774
Mailing address:
  • Phone: 918-481-2773
  • Fax: 918-481-2774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN ROADHOUSE
Title or Position: PRESIDENT
Credential:
Phone: 918-481-2773