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General NPI Number Information
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NPI Number | 1740177401
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Entity Type | Organization
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Legal Business Name | STATE OF OKLAHOMA MEDICAL CENTER LLC
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Dates
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Enumeration Date | 06/23/2025
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Last Update Date | 06/23/2025
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Provider Practice Location Address
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Address Line | 101 PARK AVE STE 1300
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City | OKLAHOMA CITY
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State | OK
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Zip | 73102-7216
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Country | US
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Telephone | 510-456-8143
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Fax |
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Provider Business Mailing Address
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Address Line | 4570 S EASTERN AVE STE 28
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City | LAS VEGAS
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State | NV
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Zip | 89119-6183
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CRISTINE HERNANDEZ
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Credential |
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Telephone | 510-456-8143
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084B0040X
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Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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