Provider Demographics
NPI:1639604101
Name:PARADIGM HORMONES -EDMOND
Entity Type:Organization
Organization Name:PARADIGM HORMONES -EDMOND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INS.CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSELLATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-703-3614
Mailing Address - Street 1:13100 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-1430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 S I 35 SERVICE RD
Practice Address - Street 2:STE 106
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3182
Practice Address - Country:US
Practice Address - Phone:405-703-3614
Practice Address - Fax:405-703-7021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center