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General NPI Number Information
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NPI Number | 1831599737
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Entity Type | Organization
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Legal Business Name | RENAISSANCE MEDICAL OF OKLAHOMA, P.C.
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Dates
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Enumeration Date | 08/27/2014
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Last Update Date | 08/27/2014
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Provider Practice Location Address
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Address Line | 8014 SOUTH 101 EAST AVE SUITE 200
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City | TULSA
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State | OK
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Zip | 74133
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Country | US
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Telephone | 479-434-4948
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 35746
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City | TULSA
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State | OK
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Zip | 74153-0746
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Country | US
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Telephone | 479-434-4948
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | CHESTER L CARLSON
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Credential | D.O.
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Telephone | 479-434-4948
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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