Provider Demographics
NPI:1114021284
Name:SOUTHERN OKLAHOMA DIAGNOSTIC CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHERN OKLAHOMA DIAGNOSTIC CENTER, LLC
Other - Org Name:OPEN MRI OF SOUTHERN OKLAHOMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAYDEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-226-8310
Mailing Address - Street 1:1111 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2354
Mailing Address - Country:US
Mailing Address - Phone:580-226-1674
Mailing Address - Fax:580-226-9674
Practice Address - Street 1:1111 WALNUT
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401
Practice Address - Country:US
Practice Address - Phone:580-226-1674
Practice Address - Fax:580-226-9674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
400522318Medicare ID - Type Unspecified