Provider Demographics
NPI:1568724532
Name:ETL PLUS, INC.
Entity Type:Organization
Organization Name:ETL PLUS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MASOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOAZAMI
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:918-749-8717
Mailing Address - Street 1:2865 E SKELLY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-6220
Mailing Address - Country:US
Mailing Address - Phone:918-749-8717
Mailing Address - Fax:918-749-8797
Practice Address - Street 1:2865 E SKELLY DR STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6220
Practice Address - Country:US
Practice Address - Phone:918-749-8717
Practice Address - Fax:918-749-8797
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EFFECTIVE TEACHING AND LEARNING INSTITUTE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100745560BMedicaid