Provider Demographics
NPI:1093293573
Name:OWASSO PAIN MANAGEMENT
Entity Type:Organization
Organization Name:OWASSO PAIN MANAGEMENT
Other - Org Name:OWASSO PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:STANDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-272-7432
Mailing Address - Street 1:12707 E 86TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-2506
Mailing Address - Country:US
Mailing Address - Phone:918-272-7432
Mailing Address - Fax:918-272-7448
Practice Address - Street 1:12707 E 86TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-2506
Practice Address - Country:US
Practice Address - Phone:918-272-7432
Practice Address - Fax:918-272-7448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty