Provider Demographics
NPI:1013024710
Name:CARESOURCE-TULSA, LLC
Entity Type:Organization
Organization Name:CARESOURCE-TULSA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-948-2822
Mailing Address - Street 1:PO BOX 270214
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73137-0214
Mailing Address - Country:US
Mailing Address - Phone:918-250-7051
Mailing Address - Fax:918-392-3442
Practice Address - Street 1:1400 SW EXPRESSWAY DR
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-250-7051
Practice Address - Fax:918-392-3442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200074940AMedicaid
OK5337220001Medicare ID - Type Unspecified