Healthcare Provider Details

I. General information

NPI: 1073600714
Provider Name (Legal Business Name): PAIN CARE ASSOCIATES OF OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 08/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6585 S YALE AVE SUITE 1110
TULSA OK
74136-8384
US

IV. Provider business mailing address

PO BOX 701683
TULSA OK
74170-1683
US

V. Phone/Fax

Practice location:
  • Phone: 918-502-7246
  • Fax: 918-519-7250
Mailing address:
  • Phone: 918-398-9683
  • Fax: 918-398-9095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number538
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4609
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25659
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number16519
License Number StateOK

VIII. Authorized Official

Name: STEPHEN T LESTER
Title or Position: OWNER
Credential: MD
Phone: 918-502-7246