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General NPI Number Information
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NPI Number | 1710128152
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Entity Type | Organization
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Legal Business Name | OSTEOPATHIC MEDICINE OF TULSA, INC.
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Dates
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Enumeration Date | 03/16/2009
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Last Update Date | 05/26/2009
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Provider Practice Location Address
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Address Line | 6465 S YALE AVE STE 804
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City | TULSA
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State | OK
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Zip | 74136-7823
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Country | US
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Telephone | 918-694-0684
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Fax |
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Provider Business Mailing Address
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Address Line | 6465 S YALE AVE STE 804
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City | TULSA
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State | OK
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Zip | 74136-7823
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Country | US
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Telephone | 918-694-0684
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | LARRY LEE ELLIS JR.
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Credential | D.O.
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Telephone | 918-694-0684
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 3803
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License Number State | OK
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