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General NPI Number Information
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NPI Number | 1124345665
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Entity Type | Organization
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Legal Business Name | SOUTHEASTERN OKLAHOMA SPORTS MEDICINE, PLLC
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Dates
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Enumeration Date | 04/23/2010
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Last Update Date | 04/23/2010
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Provider Practice Location Address
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Address Line | 1705 N WASHINGTON AVE SUITE C
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City | DURANT
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State | OK
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Zip | 74701-2100
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Country | US
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Telephone | 580-924-1414
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Fax | 580-931-0300
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Provider Business Mailing Address
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Address Line | 1705 N WASHINGTON AVE SUITE C
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City | DURANT
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State | OK
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Zip | 74701-2100
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Country | US
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Telephone | 580-924-1414
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Fax | 580-931-0300
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRIAN K RICH
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Credential | M.D.
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Telephone | 580-924-1414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 24887
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License Number State | OK
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