Provider Demographics
NPI:1740208842
Name:SOUTH TULSA OPEN MRI, LLC
Entity Type:Organization
Organization Name:SOUTH TULSA OPEN MRI, LLC
Other - Org Name:VANTAGE DIAGNOSTIC IMAGING OF TULSA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:NOFZIGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-703-4500
Mailing Address - Street 1:5909 NW EXPRESSWAY STE 300
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5103
Mailing Address - Country:US
Mailing Address - Phone:405-703-4500
Mailing Address - Fax:405-703-4501
Practice Address - Street 1:7712 S YALE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8332
Practice Address - Country:US
Practice Address - Phone:918-523-7226
Practice Address - Fax:918-523-7227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200052730BMedicaid