Healthcare Provider Details

I. General information

NPI: 1629278965
Provider Name (Legal Business Name): CENTRAL STATES ORTHOPEDIC SPECIALISTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6585 S YALE AVE 200
TULSA OK
74136-8384
US

IV. Provider business mailing address

6585 S YALE AVE 200
TULSA OK
74136-8384
US

V. Phone/Fax

Practice location:
  • Phone: 918-481-2767
  • Fax:
Mailing address:
  • Phone: 918-481-2767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number3996
License Number StateOK

VIII. Authorized Official

Name: DAVID LONG
Title or Position: CEO
Credential: CEO
Phone: 918-481-2767