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General NPI Number Information
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NPI Number | 1740722115
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Entity Type | Organization
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Legal Business Name | GREEN COUNTRY PAIN MANAGEMENT
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Dates
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Enumeration Date | 11/16/2016
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Last Update Date | 11/16/2016
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Provider Practice Location Address
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Address Line | 6048-A S SHERIDAN RD
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City | TULSA
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State | OK
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Zip | 74145
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Country | US
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Telephone | 918-935-3240
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Fax | 918-935-3241
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Provider Business Mailing Address
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Address Line | 6048-A S SHERIDAN RD
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City | TULSA
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State | OK
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Zip | 74145
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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 | SOLE MEMBER
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Name | LESLIE CHAN
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Credential | MD
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Telephone | 918-935-3240
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) 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 | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State |
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