Healthcare Provider Details

I. General information

NPI: 1689417446
Provider Name (Legal Business Name): MR. PRESTON LUKE TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W 17TH ST
TULSA OK
74107-1886
US

IV. Provider business mailing address

3008 WILLOW BROOK RD
OKLAHOMA CITY OK
73120-5725
US

V. Phone/Fax

Practice location:
  • Phone: 918-582-1972
  • Fax:
Mailing address:
  • Phone: 405-626-2713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: