Provider Demographics
NPI:1164893228
Name:SOONER PAIN CLINIC, LLC
Entity Type:Organization
Organization Name:SOONER PAIN CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-604-0901
Mailing Address - Street 1:PO BOX 270663
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73137-0663
Mailing Address - Country:US
Mailing Address - Phone:405-775-9350
Mailing Address - Fax:405-775-9350
Practice Address - Street 1:5509 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-5510
Practice Address - Country:US
Practice Address - Phone:405-604-0901
Practice Address - Fax:405-604-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-15
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18162208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty