Provider Demographics
NPI:1710277207
Name:OKLAHOMA PAIN & REHAB LLC
Entity Type:Organization
Organization Name:OKLAHOMA PAIN & REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-926-7926
Mailing Address - Street 1:2121 S COLUMBIA AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-3505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 S COLUMBIA AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3505
Practice Address - Country:US
Practice Address - Phone:918-747-0716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty