Healthcare Provider Details

I. General information

NPI: 1285011858
Provider Name (Legal Business Name): MR. JOHN T BENNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2015
Last Update Date: 05/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6333 E SKELLY DR
TULSA OK
74135-6106
US

IV. Provider business mailing address

6333 E SKELLY DR
TULSA OK
74135-6106
US

V. Phone/Fax

Practice location:
  • Phone: 918-664-4224
  • Fax:
Mailing address:
  • Phone: 918-664-4224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: