Healthcare Provider Details

I. General information

NPI: 1831924620
Provider Name (Legal Business Name): MR. THOMAS BARTLEY ENBERG I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E 81ST ST
TULSA OK
74132-2818
US

IV. Provider business mailing address

25345 E 87TH PL S
BROKEN ARROW OK
74014-6192
US

V. Phone/Fax

Practice location:
  • Phone: 469-766-8468
  • Fax:
Mailing address:
  • Phone: 469-766-8468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: