Provider Demographics
NPI:1386646313
Name:CRADLE TO COLLEGE HEALTHCARE, P.C.
Entity Type:Organization
Organization Name:CRADLE TO COLLEGE HEALTHCARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HARMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-494-5170
Mailing Address - Street 1:6565 S YALE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8303
Mailing Address - Country:US
Mailing Address - Phone:918-494-5170
Mailing Address - Fax:918-494-5196
Practice Address - Street 1:6565 S YALE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8303
Practice Address - Country:US
Practice Address - Phone:918-494-5170
Practice Address - Fax:918-494-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19827208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty