Healthcare Provider Details

I. General information

NPI: 1255810321
Provider Name (Legal Business Name): COVENANT PAIN MANAGEMENT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7615 E 63RD PL STE 104
TULSA OK
74133-1231
US

IV. Provider business mailing address

7615 E 63RD PL STE 104
TULSA OK
74133-1231
US

V. Phone/Fax

Practice location:
  • Phone: 918-307-0077
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA NUNN
Title or Position: CHIROPRACTIC
Credential:
Phone: 918-307-0077