Provider Demographics
NPI:1710317805
Name:ADVANCE PAIN MANAGEMENT OF OKLAHOMA PC
Entity Type:Organization
Organization Name:ADVANCE PAIN MANAGEMENT OF OKLAHOMA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-702-8623
Mailing Address - Street 1:3727 NW 63RD ST STE 302
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1931
Mailing Address - Country:US
Mailing Address - Phone:405-702-8623
Mailing Address - Fax:405-608-8800
Practice Address - Street 1:3727 NW 63RD ST STE 302
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1931
Practice Address - Country:US
Practice Address - Phone:405-702-8623
Practice Address - Fax:405-608-8800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-26
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200844440AMedicaid