=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578792560
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATIONS CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2009
-----------------------------------------------------
Last Update Date | 07/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6048 S SHERIDAN RD
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74145-9212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-591-3897
-----------------------------------------------------
Fax | 918-591-3899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6048 S SHERIDAN RD
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74145-9212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-591-3897
-----------------------------------------------------
Fax | 918-591-3899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MR. TRACEY FLEMONS
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 918-591-3897
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------