Provider Demographics
NPI:1275093098
Name:BRISTOW ENDEAVOR HEALTHCARE, LLC
Entity Type:Organization
Organization Name:BRISTOW ENDEAVOR HEALTHCARE, LLC
Other - Org Name:PRAGUE HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-701-2313
Mailing Address - Street 1:1809 E 13TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4431
Mailing Address - Country:US
Mailing Address - Phone:918-701-2313
Mailing Address - Fax:539-235-0028
Practice Address - Street 1:810 9TH ST
Practice Address - Street 2:
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864-4582
Practice Address - Country:US
Practice Address - Phone:405-566-3411
Practice Address - Fax:405-566-3410
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRISTOW ENDEAVOR HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-20
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty