=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710098108
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRYAN LUCENTA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 10/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10505 E 91ST ST SUITE 202
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74133-5829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-994-5580
-----------------------------------------------------
Fax | 918-994-5585
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10505 E 91ST ST SUITE 202
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74133-5829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-994-5580
-----------------------------------------------------
Fax | 918-994-5585
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRYAN ALLEN LUCENTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 918-994-5580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------