Provider Demographics
NPI:1205007531
Name:WAGONER ORTHOPEDIC CENTER
Entity Type:Organization
Organization Name:WAGONER ORTHOPEDIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEOPARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-485-5514
Mailing Address - Street 1:1202 W CHEROKEE ST STE B
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1202 W CHEROKEE ST STE B
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4629
Practice Address - Country:US
Practice Address - Phone:918-485-5514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAGONER HOSPITAL AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-14
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2298282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital